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Fundamentals Exam 1

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A nurse is admitting a client to a geriatric medicine unit following the client's recent diagnosis of acute renal failure. Which of the following nursing actions is most likely to reduce the client's chance of experiencing a fall while on the unit? A) Orient the client to the room and environment thoroughly upon admission. B) Provide the client with a bedpan to reduce the need to transfer to a commode or washroom. C) Administer pain medications sparingly in order to minimize cognitive or musculoskeletal side effects. D) Place the client in a shared room with a client who is stable and oriented. Ans:

A nurse is assessing a client during a health care camp. The nurse observes that the client has poor hygiene and an itchy, infected scalp. Which of the following should the nurse ask the client to do? A) Wash hair daily B) Use dry shampoo C) Use oil-based shampoo D) Use anti-lice shampoo

A nurse is assessing a client who recently had a stroke. What is one area of assessment necessary to promote safety? A) Neuromuscular B) Respiratory C) Gastrointestinal D) Genitourinary

A nurse is assessing a client with a stage IV pressure ulcer. What assessment of the ulcer would be expected? A) Full-thickness skin loss B) Skin pallor C) Blister formation D) Eschar formation

A nurse is assessing the activity level of an infant age 5 months. What normal findings would be assessed? A) Ability to sit and head control B) Ability to pick up small objects C) Progress toward running and jumping D) Progress toward unassisted walking

A nurse is assigned to care for a client diagnosed with asthma who has just been admitted to the health care facility. The nurse determines the client's priorities for care using which of the following? A) Assessment skills B) Nursing books C) Client's records D) Supervisor's advice

A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the resident's ability to breathe and then begins CPR. Why did the nurse assess respiratory status? A) To identify a life-threatening problem B) To establish a database for medical care C) To practice respiratory assessment skills D) To facilitate the resident's ability to breathe

A nurse is brushing the hair of a client admitted to the health care facility following a fracture in the hand. The nurse implements this action based on the understanding that brushing the hair achieves which of the following? A) Facilitates oil distribution B) Cleans hair and scalp C) Removes excess oil D) Cleans the hair of dirt

A nurse is caring for an adolescent who is diagnosed with mononucleosis, commonly called "the kissing disease." The nurse explains that the organisms causing this disease were transmitted by: A) direct contact. B) indirect contact. C) airborne route. D) vectors.

A nurse is changing the bed linen of a client admitted to the health care facility. Which of the following isolation precautions should the nurse follow? A) Standard precautions B) Droplet precautions C) Contact precautions D) Airborne precautions

A nurse is educating women on the need for calcium to prevent bone loss. What level of prevention does this represent? A) Primary prevention B) Secondary prevention C) Tertiary prevention D) Residual prevention

A nurse is evaluating and revising a plan of care for a client with cardiac catheterization. Which of the following actions should the nurse perform before revising a plan of care? A) Discuss any lack of progress with the client. B) Collect information on abnormal functions. C) Identify the client's health-related problems. D) Select appropriate nursing interventions.

A nurse is formulating a diagnosis for a client who is reliving a brutal mugging that took place several months ago. The client is crying uncontrollably and states that he "can't live with this fear." Which of the following diagnoses for this client is correctly written? A) Post-trauma syndrome related to being attacked B) Psychological overreaction related to being attacked C) Needs assistance coping with attack D) Mental distress related to being attacked

A nurse is giving a talk to a local community group on the importance of proper diet and regular exercise. This is an example of which type of health promotion? A) Primary health promotion B) Secondary health promotion C) Tertiary health promotion D) Chronic health promotion

A nurse is interested in improving client care on the unit through performance improvement. What is the first step in this process? A) Discover the problem. B) Plan a strategy. C) Implement a change. D) Assess the change.

A nurse is performing a sterile dressing change. If new sterile items or supplies are needed, how can they be added to the sterile field? A) With sterile forceps or hands wearing sterile gloves B) By carefully handling them with clean hands C) With clean forceps that touch only the outermost part of the item D) By clean hands wearing clean latex gloves

A nurse is positioning a sterile drape to extend the working area when performing a urinary catheterization. Which of the following is an appropriate technique for this procedure? A) Use sterile gloves to handle the entire drape surface. B) Fold the lower edges of the drape over the sterile-gloved hands. C) Touch only the outer two inches of the drape when not wearing sterile gloves D) When reaching over the drape do not allow clothing to touch the drape.

A nurse is preparing to provide foot care to a client who has decreased mobility. Which of the following techniques should the nurse employ when providing this care? A) Use an antifungal powder on the client's feet if necessary. B) Carefully remove any corns or calluses that are present. C) Soak the client's feet for 15 to 20 minutes prior to cleansing. D) Avoid using soaps or commercial cleansers whenever possible.

A nurse is providing an educational event to a local group of disabled citizens. What would be important for the nurse to be aware of when planning this event? A) The health promotion needs of the group the nurse is speaking to B) What the disability of each person is C) Wellness needs of each individual person D) What the families want you to talk about

A nurse is providing care for a client who has been newly admitted to the long-term care facility. What is the primary criterion for the nurse's decision whether to use a mechanized assistive device for transferring the client? A) The client's ability to assist B) The client's body weight C) The client's cognitive status D) The client's age

A nurse is providing perineal care to a female client. In which direction would the nurse move the washcloth? A) From the pubic area toward the anal area B) From the anal area to the pubic area C) From side to side within the labia D) The direction does not make any difference

A nurse is teaching an older woman how to move and lift her disabled husband. The woman has osteoarthritis of the hips and knees. What is the goal of the nurse's education plan? A) Minimize stress on the wife's joints B) Povide exercise for the husband C) Increase socialization with neighbors D) Maintain self-esteem of the wife

A nurse on duty finds that a client is anxious about the results of laboratory testing. Which intervention by the nurse reflects a supportive intervention? A) Sitting with the client to encourage her to talk B) Telling the laboratory technician to speed up the results C) Calling the physician for an order for an anxiolytic D) Educating the client about reducing risk factors

A nurse organizes client data using the SOAP format. Which of the following would be recorded under "S" of this acronym? A) Client complaints of pain B) Client history C) Client's chief complaint D) Client interventions

A nurse uses informatics to plan nursing care for a client. Which three terms best describes this science as it is applied to nursing? A) Data, information, knowledge B) Process, documentation, analysis C) Research, controls, variables D) Hypothesis, nursing, practice

A nurse uses proper body mechanics to move a client up in bed. Which of the following is a guideline for using these techniques properly? A) Face the direction of movement. B) Twist body at the waist when lifting. C) Keep body weight higher than center of gravity. D) Keep feet together to provide a base of support.

A nurse who collected and organized data during a client history realizes that there is not enough information to plan interventions. Which of the following would be the best remedy to prevent this from happening in the future? A) The nurse should practice interviewing strategies. B) The nurse should modify data collection tool. C) The nurse should determine specific purpose of data collection. D) The nurse should update the database.

A nurse who is caring for an unresponsive client formulates the nursing diagnosis, "Risk for Aspiration related to reduced level of consciousness." The nurse documents this nursing diagnosis as correct based on the understanding that which of the following is a characteristic of this type of diagnosis? A) Is written as a two-part statement B) Describes human response to a health problem C) Describes potential for enhancement to a higher state D) Made when not enough evidence supports the problem

A nurse writes the following nursing diagnosis for a client with Alzheimer's disease: Disturbed Thought Processes related to Alzheimer's disease as evidenced by incoherent language. Which part of this diagnosis is considered the problem statement? A) disturbed thought processes B) related to C) Alzheimer's disease D) incoherent language

A staff development nurse is discussing techniques to prevent back injury with a group of nursing assistants. The nurse informs the group that back stress and injury can be prevented by doing which of the following? A) Spreading feet shoulder-width apart to broaden the base of support B) Using the strength of the back muscles during strenuous activities C) Holding the object that you are lifting or moving away from the body D) Pulling equipment, rather than pushing it, when possible

A student has reviewed a client's chart before beginning assigned care. Which of the following actions violates client confidentiality? A) Writing the client's name on the student care plan B) Providing the instructor with plans for care C) Discussing the medications with a unit nurse D) Providing information to the physician about laboratory data

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) A reservoir B) An infectious agent C) A portal of exit D) A portal of entry

According to Maslow's basic human needs hierarchy, which needs are the most basic? A) Physiologic B) Safety and security C) Love and belonging D) Self-esteem

After a client falls out of bed, the nurse completes which of the following? A) Safety event report (incident report) B) Telephone call to hospital's attorney C) Progress note stating event report was completed D) Malpractice report

After assessing a client, the nurse formulates several nursing diagnoses. Which of the following would the nurse identify as an actual nursing diagnosis? A) Impaired urinary elimination B) Readiness for enhanced sleep C) Risk for infection D) Possible impaired adjustment

After assessment of a client in an ambulatory clinic, the nurse records the data on the computer. The nurse recognizes which of the following as objective data? A) Auscultation of the lungs B) Complaint of nausea C) Sensation of burning in her epigastric area D) Belief that demons are in her stomach

After completing assessments, a nurse uses the data collected to identify appropriate nursing diagnoses for a client. For what are the nursing diagnoses used? A) Selecting nursing interventions to meet expected outcomes B) Establishing a database of information for future comparison C) Mutually establishing desired outcomes of the plan of care D) Evaluating the effectiveness of the established plan of care

An elderly resident of a long-term care facility has developed diarrhea and dehydration as a result of exposure to clostridium difficile during a recent outbreak. The resident's primary care provider has consequently prescribed the antibiotic metronidazole (Flagyl). Which model of health promotion and illness prevention is most clearly evident in these events? A) The Agent-Host-Environment Model B) The Health-Illness Continuum C) The Health Promotion Model D) The Health Belief Model

An obstetrical nurse is preparing to help a client up from her bed and to the bathroom three hours after the woman delivered her baby. Which of the following actions should the nurse perform first? A) Explain to the client how the nurse will assist her. B) Position a walker in front of the client to provide stability. C) Enlist the assistance of another nurse or the physiotherapist. D) Have the client stand for 30 seconds prior to walking.

An older adult client has lost significant muscle mass during her recovery from a systemic infection. As a result, she has not yet met the outcomes for mobility and activities of daily living that are specified in her nursing plan of care. How should her nurses best respond to this situation? A) Continue the plan of care with the aim of helping the client achieve the outcomes. B) Terminate the plan of care since it does not accurately reflect the client's abilities. C) Modify the plan of care to better reflect the client's current functional ability. D) Replace the client's individualized plan of care with a clinical pathway.

An older adult client is receiving care on a rehabilitative medicine unit during her recovery from a stroke. She complains that the physical therapist, occupational therapist, neurologist, primary care physician, and speech language pathologist "don't seem to be on the same page" and that "everyone has their own plan for me." How can the nurse best respond to the client's frustration? A) Facilitate communication between the different professionals and attempt to coordinate care. B) Educate the client about the unique scope and focus of each member of the healthvcare team. C) Modify the client's plan of care to better reflect the commonalities between the different disciplines. D) Arrange for each professional to perform bedside assessments and interventions simultaneously rather than individually.

An older adult client with Parkinson's disease is unable to take care of himself. The client frequently soils his bed and is unable to clean himself independently. How should the nurse in this case ensure the client's perineal care? A) Cleanse to remove secretions from less-soiled to more-soiled areas. B) Cleanse using a cotton cloth and warm water. C) Use tissue rolls to clean the client's perineal area. D) Provide the client with a bed pan or a jar to collect the urine

An older adult resident of a long-term care facility has recurring problems with dry skin. Which of the following strategies should the nursing staff utilize in order to help meet the resident's hygiene needs while preventing skin dryness? A) Use a nonsoap cleaning agent. B) Use organic soap and shampoo. C) Bathe the client more often, but without using soap or shampoo. D) Provide the client with bed baths rather than tub baths

An unconscious patient is brought to the emergency department. Which of the following assessments should be implemented first? A) The client's airway should be assessed. B) The nurse should determine the reason for admission. C) The nurse should review the client's medications. D) The client's past medical history is assessed.

An unmarried couple in a committed relationship live together with their adopted twin boys. Which of the following best describes this type of family? A) Nuclear family B) Extended family C) Blended family D) Adoptive family

Based on a community assessment, the nurse has set the following outcomes. Which outcome reflects Maslow's level of safety and security needs? A) The community will establish an effective wastewater disposal system by January 22. B) The community will demonstrate pride by posting a welcome sign and flowers at the edge of town by April 8. C) The community will open a senior citizens center by March 9. D) The community will identify a walking path through the community by February 2.

During the course of assessing the family structure and behaviors of a pediatric patient's family, the nurse has identified a number of highly significant risk factors. Which of the following actions should the nurse prioritize when addressing these risk factors? A) Engage in appropriate health promotion activities. B) Validate the family's unique way of being. C) Enlist the help of community and social support. D) Introduce the family to another family that possesses fewer risk factors.

Each time a nurse administers an insulin injection to a client with diabetes, she tells the client what she is doing and demonstrates each step of preparing and giving the injection. What is the nurse promoting in the client? A) Self-care B) Dependence C) Competence D) Discipline

In light of the failure of alternatives, a nurse has been forced to physically restrain an agitated client. Which of the following actions should the nurse perform when applying and maintaining the restraints? A) Tie the client's hand restraint to the bed frame rather than the side rail. B) Obtain a physician's order for the restraints within 24 hours. C) Ensure the client is under continuous surveillance while restrained. D) Choose a restraint device that best minimizes the client's mobility.

In planning the care for a client who has pneumonia, the nurse collects data and develops nursing diagnoses. Which of the following is an example of a properly developed nursing diagnosis? A) Ineffective airway clearance as evidenced by inability to clear secretions B) Ineffective health maintenance as evidenced by unhealthy habits C) Ineffective breathing pattern related to pneumonia D) Ineffective therapeutic regimen management due to smoking

In the nursing diagnosis Disturbed Self-Esteem related to presence of large scar over left side of face, what part of the nursing diagnosis is "presence of large scar over left side of face"? A) Etiology B) Problem C) Defining characteristics D) Client need

Increasingly, health care institutions are implementing computerized plans of nursing care. A benefit of using computerized plans includes which of the following? A) Reduction in the time spent on care planning B) Increased autonomy related to the nursing care planning process C) Enhanced individualization of a care plan D) Increased nursing expertise in care planning

Many of the homeless clients who are supposed to receive care for HIV/AIDS miss their appointments at a clinic because it is located in a high-rise building on a university campus. Several of the clients state that the clinic is difficult to find and in an intimidating environment. This demonstrates that which of the following variables influencing outcome achievement is being inadequately addressed? A) Psychosocial background of clients B) Developmental stage of clients C) Ethical and legal considerations D) Resources

Nurses have identified the following outcome in the care of a client who is recovering from a stroke: "Client will ambulate 100 feet without the use of mobility aids by 12/12/2011." Several nurses have evaluated the client's progression towards this outcome at various points during her care. Which of the following evaluative statements is most appropriate? A) "12/12/2011 - Outcome partially met. Patient ambulated 75 feet without the use of mobility aids" B) "12/12/2011 - Outcome unmet. Patient's ambulation remains inadequate." C) "12/10/2011 Outcome met, but with the use of a quad cane to assist ambulation." D) "12/14/2011 Outcome met."

Nurses make common errors in the identification and development of outcomes. Which of the following is a common error made when writing client outcomes? A) The nurse expresses the client outcome as a nursing intervention. B) The nurse develops measurable outcomes using verbs that are observable. C) The nurse develops a target time when the client is expected to achieve that outcome. D) The outcome should include a subject, verb, conditions, performance criteria, and target time.

Nursing care and client outcomes may be evaluated by use of a retrospective evaluation process. Which of the following is an example of a retrospective evaluation process? A) Postdischarge questionnaire. B) Direct observation of nursing care. C) Client interview during hospitalization. D) Review of client's chart during hospitalization.

The American Nurses Association recommends adherence to defined principles when delegating care tasks to unlicensed assistive personnel. According to these principles, who is responsible and accountable for nursing practice? A) The registered nurse B) The American Nurses Association C) The nurse manager D) The unit's medical director

The client reports participating in water aerobics for 60 minutes three times each week. This is an example of what type of outcome? A) Affective outcome B) Psychomotor outcome C) Physiologic outcome D) Cognitive outcome

The clinical nurse educator at a long-term care facility is responsible for organizing and carrying out staff education sessions. Which of the following topics for staff education is most likely to benefit the greatest number of residents? A) Educating nurses on how to prevent falls B) Reviewing safe medication administration C) Educating nurses on how to prevent wandering by confused residents D) Reviewing resuscitation for cardiac and respiratory arrest

The community health nurse is creating a plan of care for a client with Parkinson's disease. The client's spouse has provided care to the client for the past five years and the client's care needs are increasing. What is an appropriate nursing diagnosis for the client and family? A) Risk for Caregiver Role Strain. B) Health Seeking Behaviors. C) Parental Role Conflict. D) Readiness for Enhanced Family Processes.

The correct sequence of steps for performance improvement is: 1. Discover a problem. 2. Plan a strategy using indicators. 3. Implement a change. 4. Assess the change. A) 1, 2, 3, 4 B) 1, 4, 2, 3 C) 4, 1, 2, 3 D) 1, 2, 4, 3 E) 1, 3, 2, 4

The manager of a medical unit regularly reviews the incident reports that result from errors and near misses that occur on the unit. How should the manager best respond to these incident reports? A) Use them to inform improvements and education on the unit. B) Use them to identify deficient workers for removal or demotion. C) Cross-reference them with client satisfaction reports from the unit. D) Use them to identify individuals who would benefit from probationary measures.

The mother of a toddler with asthma seeks support from the parents of other children with asthma. The nurse recognizes that seeking and utilizing support systems is an example of which human dimension? A) Sociocultural dimension B) Physical dimension C) Environmental dimension D) Intellectual and spiritual dimension

The nurse and nursing aid are providing perineal care for an incontinent client. What information is important for the nurse to consider when providing perineal care? A) Apply moisture barriers to the skin of the perineal area. B) Provide excessive hydration to the skin of the perineal area. C) Wash the perineal area frequently with soap and water. D) Aggressively cleanse the perineal area with a washcloth or towel.

The nurse assists the client to the bathroom sink to perform morning care. The nurse observes the client wash his face, arms, abdomen, and legs. The nurse washes the client's back and rectal area and applies soap to the back. The client brushes his teeth and ambulates to a chair in his room with assistance. How will the nurse describe the morning care on the client's chart? A) Partial care B) As-needed care C) Self-care D) Complete care

The nurse cares for a newly admitted client who will soon need to be taken to the radiology department for a CT scan. The client has a Body Mass Index (BMI) of 52. Which of the following strategies to transport the client is most appropriate? A) Obtain a mechanical lateral transfer device to move the client onto a stretcher. B) Enlist the aid of two other staff members and pull the client across the bed and onto a stretcher. C) Position a friction-reducing sheet under the client before attempting the transfer. D) Transport the client to the radiology department in the hospital bed.

The nurse develops long-term and short-term outcomes for a client admitted with asthma. Which of the following is an example of a long-term goal? A) Client returns home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack. B) By day 3 of hospitalization, the client verbalizes knowledge of factors that exacerbate the symptoms of asthma. C) Within one hour of a nebulizer treatment, adventitious breath sounds and cough are decreased. D) Within 72 hours of admission, the client's respiratory rate returns to normal and retractions disappear

The nurse has completed an assessment of a client's typical hygiene practices. How should the nurse best document the findings of this assessment in the client's chart? A) "Client normally bathes and washes her hair every other day; applies moisturizer to dry areas on her elbows and forearms." B) "Client prioritizes personal hygiene in her daily routines and is proactive with skin care." C) "Client bathes more often than necessary and consequently experiences dry skin." D) "Client's level of personal hygiene is acceptable and age-appropriate."

The nurse has completed bed bath on a client who is obese. The client asks you to sprinkle baby powder in the perineal area. Which of the following actions is correct? A) Inform the client that baby powder is not used because it may become a medium for bacterial growth. B) Carefully apply baby powder to skin folds only. C) Pour a small amount of powder into the hand and gently pat the perineal area while avoiding aerosolization of the powder. D) Apply a generous amount of baby powder to all areas where skin touches skin.

The nurse has drafted a nursing diagnosis of Imbalanced Nutrition: More Than Body Requirements in the care of moderately obese client. How should the nurse proceed after writing this diagnosis? A) Validate the nursing diagnosis B) Identify potential complications C) Cross-reference the nursing diagnosis with medical diagnoses D) Modify interventions based on the diagnosis

The nurse has entered a client's room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference? A) Measure the client's oral temperature. B) Ask a colleague for assistance. C) Give the client a clean gown and warm blankets. D) Obtain an order for blood cultures

The nurse has identified a number of risk nursing diagnoses in the care of an adolescent who has been admitted to the hospital for treatment of an eating disorder. These risk diagnoses indicate which of the following? A) The client is more vulnerable to certain problems than other individuals would be. B) The diagnoses present significant risks for the development of medical diagnoses. C) The data necessary to make a definitive nursing diagnosis is absent. D) The diagnosis has yet to be confirmed by another practitioner.

The nurse has responded to a client's request to view her medical chart by arranging a meeting between the client, the clinical nurse leader, and her primary care physician. The nurse is exemplifying which of the following characteristics of quality health care? A) Information B) Science C) Cooperation D) Individualization

The nurse is assessing a client with a diagnosis of hypertension. The client's blood pressure is 178/88, an increase from 134/78 at the previous clinic visit. The nurse asks the client what has changed from the previous visit. Which client statement identifies a potential factor interfering with the plan of care? A) My husband has been ill and I don't have anyone to help me care for him. B) I have learned to prepare foods differently so they are low in fat. C) My neighbor walks with me around the neighborhood every morning. D) I have been taking my hydrochlorothiazide (HydroDIURIL) every day

The nurse is aware that an antiviral medication is most effective when given during which phase of the infectious process? A) Prodromal stage B) Incubation period C) Full stage of illness D) Convalescent period

What common problem is related to outcome identification and planning? A) Failing to involve the client in the planning process B) Collecting sufficient data to establish a database C) Stating specific and measurable outcomes based on nursing diagnoses D) Writing nursing orders that are clear and resolve the problem

What is one method by which a nurse can be a role model to promote health in the community? A) Demonstrating a healthy lifestyle B) Becoming a member of a family C) Meeting own basic needs D) Exhibiting self-actualization

What is the minimal amount of time that a nurse should scrub hands that are not visibly soiled for effective hand hygiene? A) 20 seconds B) 30 seconds C) 1 minute D) 5 minutes

What is the primary purpose of an incident report? A) Means of identifying risks B) Basis for staff evaluation C) Basis for disciplinary action D) Format for audiotaped report

What is the unique focus of nursing implementation? A) Client response to health and illness B) Client response to nursing diagnosis C) Client compliance with treatment regimen D) Client interview and physical assessment

What phrase best describes health? A) Individually defined by each person B) Experienced by each person in exactly the same way C) The opposite of illness D) The absence of disease

When documenting subjective data, the nurse should do which of the following? A) Use the client's own words placed in quotation marks. B) Paraphrase the information stated by the client. C) Validate the information with the client's family prior to documentation. D) Record the information using nonspecific words.

When measuring the size, depth, and wound tunneling of a client's stage IV pressure ulcer, what action should the nurse perform first? A) Perform hand hygiene. B) Insert a swab into the wound at 90 degrees. C) Measure the width of the wound with a disposable ruler. D) Assess the condition of the visible wound bed

When moving a client up in bed, the nurse asks the client to fold the arms across the chest and lift the head with the chin on the chest. What is the rationale for placing the client in this position? A) To prevent hyperextension of the neck B) To prevent pressure on the arms C) To lower the client's center of gravity D) To decrease the effort needed to move the client

Which activity is a possible solution for inadequate nursing staffing? A) Identify the kind and amount of nursing services required. B) Learn to give quality care during designated work period. C) Use a team conference to develop a consistent plan of care. D) Educate the client to become an assertive health care consumer

Which client is most likely to require hospitalization related to problems associated with the feet? A) A client with peripheral vascular disease B) A client with osteoporosis C) A client with asthma D) A client with diabetes insipid

Which intervention does the nurse recognize as a collaborative intervention? A) Teach the client how to walk with a three-point crutch gait. B) Administer spironolactone (Aldactone). C) Perform tracheostomy care every eight hours. D) Straight catheterize every six hours.

Which of the following activities related to respiratory health is an example of tertiary health promotion and illness prevention? A) Administering a nebulized bronchodilator to a client who is short of breath B) Assisting with lung function testing of a client to help determine a diagnosis C) Teaching a client that "light" cigarettes do not prevent lung disease D) Advocating politically for more explicit warning labels on cigarette packages

Which of the following clients is most likely to face an increased risk of falls due to his or her medication regimen? A) A female client age 77 years who has received a benzodiazepine to minimize her anxiety B) A male client age 79 years whose recent high blood pressure has required a PRN dose of an angiotensin-converting enzyme (ACE) inhibitor C) A woman age 81 years who has required a blood transfusion to treat a gastrointestinal bleed D) A man 90 years of age whose venous ulcer has required the administration of intravenous antibiotics

Which of the following guidelines should a nursing instructor provide to nursing students who are now responsible for assessing their clients? A) "Assessment data about the client should be collected continuously." B) "Assess your client after receiving the nursing report and again before giving a report to the next shift of nurses." C) "Assess your client at least hourly if the client's vital signs are unstable, and every two hours if the vital signs are stable." D) "Assessment data should be collected prior to the physician rounding on the unit."

Which of the following individuals would the nurse assess as being most at risk for altered family health? A) An unmarried adolescent with a newborn B) A newly married couple who ask about birth control C) A middle-aged man and woman with no children D) An older adult, living in an assisted-living community

Which of the following is a correct guideline to follow when composing a nursing diagnosis statement? A) Place defining characteristics after the etiology and link them by the phrase "as evidenced by." B) Phrase the nursing diagnosis as a client need. C) Place the etiology prior to the client problem and linked by the phrase "related to." D) Incorporate subjective and judgmental terminology.

Which of the following is not one of the six general types of risk factors in regard to increasing an individual 's chances for illness and injury? A) Gender B) Age C) Environment D) Lifestyle

Which of the following measures should nurses implement in a hospital setting in order to identify intimate partner violence (IPV)? A) Routine screening of newly admitted clients B) Focused physical assessment for IPV for all new clients C) Involvement of a social worker in the admission assessment of all new female clients D) Review of the definition and legal repercussions of IPV with all new female clients

Which of the following models of health promotion and illness prevention was developed to illustrate how people interact with their environment as they pursue health? A) The health promotion model B) The health belief model C) The health-illness continuum D) The agent-host-environment model

A client 86 years of age with a diagnosis of late-stage Alzheimer's disease requires full assistance with transfers to and from his bed. Which of the following nursing actions is most likely to promote safe handling of this client? A) Provide to the client brief, clear instructions that are phrased positively. B) Post written instructions at the client's bedside to supplement spoken instructions. C) Ask for the client's input on the timing and technique for transfers. D) Ask for the client's feedback frequently during transfers.

A client arrives at the emergency department with nausea, hematemesis, fever, abdominal pain, and severe diarrhea. There is a suspicion the client has been exposed to the anthrax bacillus. What category of medications will be administered? A) Antimicrobials B) Narcotics C) Antihistamines D) Antacids

A client being prepared for discharge to his home will require several interventions in the home environment. The nurse informs the discharge planning team, consisting of a home health care nurse, physical therapist, and speech therapist, of the client's discharge needs. This interaction is an example of which professional nursing relationship? A) Nurse-health care team B) Nurse-patient C) Nurse-patient-family D) Nurse-nurse

A client is brought to the emergency department in an unconscious condition. The client's wife hands over the previous medical files and points out that the client had suddenly fallen unconscious after trying to get out of bed. Which of the following is a primary source of information? A) Client's wife B) Medical documents C) Test results D) Assessment data

A client with a new colostomy often becomes short and sarcastic when nurses attempt to teach him about the management of his new appliance. The nurse has consequently documented "Noncompliance related hostility" on the client's chart. What mistake has the nurse made when choosing and documenting this nursing diagnosis? A) Presuming to know the factors contributing to the problem B) Identifying a problem that cannot be changed C) Identifying a problem without corroborating evidence in the statement D) Neglecting to identify potential complications related to the problem

A client with an upper respiratory infection (common cold) tells the nurse, "I am so angry with the nurse practitioner because he would not give me any antibiotics." What would be the most accurate response by the nurse? A) "Antibiotics have no effect on viruses." B) "Let me talk to him and see what we can do." C) "Why do you think you need an antibiotic?" D) "I know what you mean; you need an antibiotic."

A client with diabetes has impaired sensation in her lower extremities. What education would be necessary to reduce her risk of injury? A) "Always test the temperature of bath water before stepping in." B) "Take your insulin twice a day as we have discussed." C) "Remember to follow your diet so you lose weight this month." D) "Rub lotion on the skin of your legs and feet twice a day."

A client's diagnosis of pneumonia requires treatment with antibiotics. The corresponding order in the client's chart should be written as ... A) Avelox (moxifloxacin) 400 mg daily B) Avelox (moxifloxacin) 400 mg Q.D. C) Avelox (moxifloxacin) 400 mg qd D) Avelox (moxifloxacin) 400 mg OD

A female client 89 years of age has been admitted to the hospital with a diagnosis of failure to thrive. She has become constipated in recent days, in spite of maintaining a high fluid intake and taking oral stool softeners. She admits to her nurse that the problem is rooted in the fact that she feels mortified to attempt a bowel movement on a commode at her bedside where staff and other clients can hear her. The nurse should respond by modifying which of the following resources? A) Environment B) Personnel C) Equipment D) Patient and visitors

A female client is on isolation because she acquired a methicillin-resistant S. aureus (MRSA) infection after hospitalization for hip replacement surgery. What name is given to this type of infection? A) Nosocomial B) Viral C) Iatrogenic D) Antimicrobial

A girl age 4 years has been admitted to the emergency department after accidently ingesting a cleaning product. Which of the following treatments is most likely appropriate in the immediate treatment of the girl's poisoning? A) Administration of activated charcoal B) Inducing vomiting C) Gastric lavage D) Intravenous rehydration

A graduate nurse recently attended a conference on acute coronary syndrome. In preparing a plan of care for a client admitted with acute coronary syndrome, the nurse considers the information she learned at the conference. Which nursing variable is the nurse utilizing in the development of the plan of care? A) Research findings B) Resources C) Current standards of care D) Ethical and legal guides to practice

A homeless client has been brought to the emergency department (ED) by ambulance after being found unresponsive outside a mall. The client is known to the ED staff as having bipolar disorder, and assessment reveals likely cellulitis on his left ankle. He is febrile with a productive cough, and the care team suspects pneumonia. A sputum culture for tuberculosis has been obtained and sent to the laboratory. Which of the following aspects of the client's medical condition would be considered a chronic condition? A) Bipolar disorder B) Pneumonia C) Cellulitis D) Tuberculosis

A homeless person uses the soap and towels in a public restroom to wash up. This is an example of which type of factor affecting personal hygiene practices? A) Socioeconomic class B) Culture C) Developmental level D) Health state

A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's following statements would appear at the beginning of a charting entry? A) "Client complaining of abdominal pain rated at 8/10." B) "Client is guarding her abdomen and occasionally moaning." C) "Client has a history of recent abdominal pain." D) "2 mg Dilaudid PO administered with good effect"

A male client 30 years of age is postoperative day 2 following a nephrectomy (kidney removal) but has not yet mobilized or dangled at the bedside. Which of the following is the nurse's best intervention in this client's care? A) Educate the client about the benefits of early mobilization and offer to assist him. B) Respect the client's wishes to remain in his bed and ask him when he would like to begin mobilizing. C) Show the client the expected outcomes on his clinical pathway that relate to mobilization. D) Document the client's noncompliance and reiterate the consequences of delaying mobilization.

A male client is scheduled to be fitted with a prosthesis following the loss of his nondominant hand in a farm accident several weeks earlier. Nurses have documented the following outcome during this stage of his care: "After attending an educational session, client will demonstrate correct technique for applying his prosthesis." Which of this client's following statements would signal a need to amend this outcome? A) "I'm not interested one bit in wearing an artificial hand." B) "I'm worried that I'm going to get some really strange looks when I wear this thing." C) "I don't have a clue how this thing goes on and comes off." D) "I don't understand the technology that's used in this artificial hand."

A novice nurse collects data on a newly admitted client. Upon evaluation of this data, the nurse provides an erroneous interpretation. What is a corrective action for this interpretation? A) Encourage the novice nurse to independently observe the same situation with a peer, validate the data, and discuss the situation afterward. B) Encourage the novice nurse to develop his or her own tool for data collection. C) Encourage the novice nurse to collect and interpret the data for the client repeatedly, until the novice nurse arrives at the correct interpretation. D) Encourage the novice nurse to meet with the nurse manager to discuss the situation and seek mentoring for communication skills.

A nurse assigned to a client's care schedules a family assessment of the client. Which of the following should the nurse use for basic family assessment? A) Interview B) Physical assessment C) Survey D) Poll

A nurse caring for a client in a long-term health care facility measures his intake and output and weighs him to assess water balance. These actions help to meet which of Maslow's hierarchy of needs? A) Physiologic B) Safety and security C) Love and belonging D) Self-actualization

A nurse caring for a client who is being treated by three physicians uses the source-oriented format for documentation. What are the benefits of using this format of documentation? A) Information is documented in separate forms by each health care personnel. B) It is a unified, cooperative approach for resolving the client's problems. C) It is organized at one location according to the client's health problems. D) It is compiled to facilitate communication among health care professionals.

A nurse completes a health history and physical assessment for an adolescent before he begins football practice. Based on findings, the nurse recommends reinforcing good health habits. What conclusion did the nurse reach after interpreting and analyzing the data? A) No problem B) Possible problem C) Actual problem D) Clinical problem

A nurse educator uses models of health and illness when teaching. Which model of health and illness places high-level health and death on opposite ends of a graduated scale? A) Health-Illness Continuum B) Agent-Host-Environment Model C) Health Belief Model D) Health Promotion Model

A nurse has seen several clients at a community health center. Which of the clients would be most at risk for developing an infection? A) An older adult with several chronic illnesses B) An infant who has just received first immunizations C) An adolescent who had a basketball physical D) A middle-aged adult with joint pain and stiffness

A nurse in a community health center has been having regular meetings with a woman who wants to stop smoking. Which of the following outcome decision options would the nurse document if the woman has not smoked for three months? A) Outcome met B) Outcome partially met C) Outcome not met D) Outcome inappropriate

Which of the following nursing interventions is an example of health promotion and preventive care on the primary level? SELECT ALL THAT APPLY A) A nurse counsels a teenager to stop smoking. B) A nurse conducts a health fair for high blood pressure screening. C) A nurse counsels the family of a client diagnosed with lung cancer. D) A home health care nurse arranges for rehabilitation services for a patient. E) A school nurse arranges for a career seminar for graduating seniors.

Which of the following provides the nurse with the most reliable basis on which to choose a nursing diagnosis? A) A cluster of several significant cues of data that suggest a particular health problem B) A single, definitive cue that is closely associated with a common diagnosis C) A cue that can be verified by objective, medical data D) A group of related nursing diagnoses that exist within the same NANDA-approved domain

Which of the following reflects the diagnosis phase? A) The nurse identifies that the client does not tolerate activity. B) The nurse performs wound care using sterile technique. C) The nurse sets a tolerable pain rating with the client. D) The nurse documents the client's response to pain medication.

Which of the following statements about glove use and hand hygiene is true? A) Artificial fingernails should not be worn by staff involved in direct client care. B) Nonsterile gloves can be decontaminated with alcohol-based hand rub, but must be changed between clients. C) Use of alcohol-based hand rubs is appropriate after using the restroom. D) The use of sterile gloves reduces the need for hand hygiene.

Which of the following statements accurately describes how Maslow's theory can be applied to nursing practice? A) Nurses can apply this theory to the nursing process. B) Nurses can identify met needs as health care needs. C) Nurses cannot use the theory on infants or children. D) Nurses use the theory for ill, as opposed to healthy, patients.

Which of the following statements illustrates the effect of the sociocultural dimension on health and illness? A) "Why shouldn't I drink and drive? Everyone else does." B) "My mother has sickle cell anemia, and so do I." C) "I know I have heart problems, so I have changed my diet." D) "I used biofeedback to lower my blood pressure."

Which one of the following methods of documentation is organized around client diagnoses rather than around patient information? A) Problem-oriented medical record (POMR) B) Source-oriented record C) PIE charting system D) focus charting

While being measured for anti-embolism stockings, the client asks the nurse why they are necessary. What would be the nurse's best response? A) They promote venous blood return to the heart. B) They eliminate peripheral edema. C) They provide a nonslip foot surface to help prevent falls. D) They reduce the risk for impaired skin integrity.

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) Plaque C) Halitosis D) Caries

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. Which of the following is the correct name of this wound? A) Stage II pressure ulcer B) Stage I pressure ulcer C) Stage III pressure ulcer D) Stage IV pressure ulcer

While performing a physical examination on a client, the nurse observes that the client has scoliosis based on which of the following? A) Lateral deviation of the thoracic spine B) Concave curvature of the cervical spine C) Convex curvature of the thoracic spine D) Concave curvature of the lumbar spine

While receiving a report, the nurse learns that a client has paraplegia. The nurse will plan care for this client based upon the understanding that the client has which of the following? A) Paralysis of the legs B) Weakness affecting one-half of the body C) Paralysis affecting one-half of the body D) Paralysis of the legs and arms

Which of the following are examples of incidental disclosures of client health information that are permitted? SELECT ALL THAT APPLY A) A nurse working in a physician's office puts out a sign-in sheet for incoming clients. B) Two nurses are overheard talking about a client through the door of an empty client room. C) A nurse places a client chart in a holder on the examining room door with the name facing out. D) A nurse leaves an x-ray on a light board in the hallway that leads to the examining rooms. E) A nurse calls out the name of a client who is seated in the waiting room.

A B E

Which of the following populations, based on their development stage, would benefit from strategies to prevent falls? SELECT ALL THAT APPLY A) Newborns B) Toddlers C) Adolescents D) Adults E) Older Adults

A B E

Which of the following statements accurately describes the impact on nursing of using NIC/NOC standardized languages? SELECT ALL THAT APPLY A) They demonstrate the impact that nurses have on the system of health care delivery. B) They standardize and define the knowledge base for nursing curricula and practice. C) They limit the number of appropriate nursing interventions to be selected. D) They hinder the teaching of clinical decision making to novice nurses. E) They enable researchers to examine the effectiveness and cost of nursing care.

A B E

In which of the following clients has the order of priorities for nursing diagnoses changed? SELECT ALL THAT APPLY A) A client in a long-term care facility who had a stroke B) A client who is recovering from a broken leg C) A client who insists on using the bathroom instead of a bedpan D) A client who appears confused after taking pain medication E) A pregnant client whose contractions are progressing as anticipated

A C D

On which of the following components is Rosenstock's health belief model based? SELECT ALL THAT APPLY A) Perceived susceptibility to a disease B) Perceived consequences of treating disease C) Perceived seriousness of a disease D) Perceived benefits of action E) Perceived immunity to disease

A C D

The nurse is trying to determine factors influencing a client who is not following the plan of care. Which client statement identifies a potential factor interfering with following the plan of care? SELECT ALL THAT APPLY A) I don't drive so I was unable to fill my prescription. B) I consult the list of low sodium foods when preparing meals. C) My social security check does not come until next week. D) I dropped the strips for my finger-stick blood glucose testing in the bath water. E) "My daughter helps me with my range of motion exercises every morning and afternoon."

A C D

Which of the following clients would be considered at risk for skin alterations? SELECT ALL THAT APPLY A) A teenager with multiple body piercings B) A homosexual in a monogamous relationship C) A client receiving radiation therapy D) A client undergoing cardiac monitoring E) A client with diabetes

A C E

Which of the following is a correctly written client goal? SELECT ALL THAT APPLY A) The client will identify five low-sodium foods by October 9. B) The client will know the signs and symptoms of infection. C) The client will rate pain as a 3 or less on a 10-point scale by 5 pm today. D) The client will understand the side effects of digoxin (Lanoxin). E) The client will eat at least 75% of all meals by May 5.

A C E

A nurse working in a hospital setting discovers problems with the delivery of nursing care on the pediatric unit. Which of the following suggestions from the Institute of Medicine's Committee on Quality of Health Care in America (Kohn, Corrigan, & Donaldson, 2000) could help redesign and improve care? SELECT ALL THAT APPLY A) Base care on continuous healing relationships. B) Customize care based on available resources. C) Keep the nurse as the source of control. D) Share knowledge and allow for free flow of information. E) Practice evidence-based decision making.

A D E

What care should the nurse take when providing foot care for a client with peripheral vascular disease? SELECT ALL THAT APPLY A) Use an emery board to file toe nail edges B) Cut the toenails short C) Cut the nail in one piece D) Avoid cutting into calluses E) Cut the nails straight across

A D E

Which example reflects client variables that influence outcome achievement? SELECT ALL THAT APPLY A) The client was born with cystic fibrosis. B) The nurse works at a hospital in a diverse community. C) Nursing interventions are consistent with standards of care. D) The client is a college graduate and is employed. E) The client engages in activities associated with Ramadan

A D E

Which of the following are examples of common factors in a client that may influence assessment priorities? SELECT ALL THAT APPLY A) Diet and exercise program B) Standing in the community C) Ability to pay for services D) Developmental stage E) Need for nursing

A D E

Which of the following data regarding a client with a diagnosis of colon cancer are subjective? SELECT ALL THAT APPLY A) The client's chemotherapy causes him nausea and loss of appetite. B) The client became teary when his daughter from out of state came to the bedside. C) The client's ileostomy put out 125 mL of effluent in the past four hours. D) The patient is unwilling to manipulate or empty his ostomy bag. E) The patient has been experiencing fatigue in recent weeks.

A E

A resident of a long-term care facility refuses to eat until she has had her hair combed and her make-up applied. In this case, what client need should have priority? A) The need to have nutrition B) The need to feel good about oneself C) The need to live in a safe environment D) The need for love from others

A school nurse is assessing children in the third grade for pediculosis capitis. What assessments should be made? A) The pubic area for growth of hair B) The head for nits on hair shafts C) The nails for evidence of cleanliness D) The body for evidence of abuse

Alice Jones, a registered nurse, is documenting assessments at the beginning of her shift. How should she sign the entry? A) Alice J, RN B) A. Jones, RN C) Alice Jones D) AJRN

An adolescent has recently had a ring inserted into her navel. Which of the following is the greatest risk facing the adolescent as a result of this activity? A) A scar over the navel B) A local and/or systemic infection C) A greater acceptance by peers D) A strained relationship with parents

Critical thinking is an essential component in all phases of the nursing process. What question might be used to facilitate critical thinking during outcome identification and planning? A) "How do I best cluster these data and cues to identify problems?" B) "What problems require my immediate attention or that of the team?" C) "What major defining characteristics are present for a nursing diagnosis?" D) "How do I document care accurately and legally?"

Educating clients on their diabetic regimen of administering insulin is the implementation of which skill? A) Intrinsic B) Technical C) Interpersonal D) Visual

Five functions have been identified as being essential to the growth of individuals and families. One of these functions is education and support. How is support manifested in the context of coping with crisis and illness situations? A) Making clear distinctions between the generations B) Actions that tell family members they are cared about and loved C) The promotion of exercise in the lifestyle D) Transmitting culture and acceptable behaviors

In what type of documentation method would a nurse document narrative notes in a nursing section? A) Problem-oriented medical record B) Source-oriented record C) PIE charting system D) Focus charting

Of the following types of nursing diagnoses, which one is validated by the presence of major defining characteristics? A) Risk nursing diagnosis B) Actual nursing diagnosis C) Possible nursing diagnosis D) Wellness diagnosis

On the first postoperative day, the client is assisted to the bathroom. It is important for the nurse to do what? A) Allow the client privacy B) Assess the client's safety C) Assess the client's pain D) Allow sufficient time

Once applied, antiembolism stockings should not be removed until the primary care provider writes an order to discontinue them. A) True B) False

Prior to inserting a nasogastric tube, the nurse correctly verifies the client's identity through which of the following methods? A) Ask the client: "Is your name____ ?" B) Check the client's identification bracelet. C) Verify the client's room number. D) Call the client by his or her first name

Student nurses are turning a client in bed. In order to move the client to the edge of the bed, which positioning instruction is best to give the client when using the friction-reducing sheet? A) Cross the arms across the chest and keep the legs straight. B) Cross the arms across the chest and cross the legs. C) Keep the arms at the sides and the legs crossed. D) Keep the arms folded loosely at the abdomen and the legs straight.

The nurse conducting a community emergency preparedness education class includes which of the following as an example of a natural disaster? A) Toxic spill B) Earthquake C) War D) Terrorist event

The nurse is helping a client walk in the hallway when the client suddenly reaches for the handrail and states, "I feel so weak. I think I am going to pass out." Which of the following initial actions by the nurse is appropriate? A) Firmly grasp the client's gait belt. B) Support the client's body against yours and gently slide the client onto the floor. C) Ask the client to lean against the wall while you obtain a wheelchair. D) Apply oxygen and wait several minutes for the weakness to pass. E) Ask the patient, "When was the last time you ate?"

The nurse is preparing to move a patient up in bed with the assistance of another nurse. In what position would the nurse place the patient, if tolerated? A) Reverse Trendelenburg B) Supine C) Sitting D) Semi-Fowler's

The nursing student asks the nurse about nurse-initiated and physician-initiated interventions. Which of the following is a physician-initiated intervention? A) Teach client how to transfer from bed to chair and chair to bed. B) Administer oxygen 4 L/min per nasal cannula. C) Assist the client with coughing and deep breathing every hour. D) Monitor intake and output every 2 hours.

The researchers developing classifications for interventions are also committed to developing a classification of which of the following? A) Diagnoses B) Outcomes C) Goals D) Data clusters

What are the general nursing care guidelines that the nurse should follow when caring for clients in a health care facility? A) Avoid physical contact with the infected client. B) Avoid jewelry with prongs or protruding stones. C) Isolate the client and keep the room door closed. D) Shake linens properly when changing the beds.

What cognitive processes must the nurse use to measure client achievement of outcomes during evaluation? A) Intuitive thinking B) Critical thinking C) Traditional knowing D) Rote memory

What intervention should be included on a plan of care to prevent pressure ulcer development in health care settings? A) Change position at least once each shift. B) Implement a turning schedule every two hours. C) Use ring cushions for heels and elbows. D) Do not turn; use pressure-relieving support surface.

What is the focus of a diagnostic statement for a collaborative problem? A) The client problem B) The potential complication C) The nursing diagnosis D) The medical diagnosis

What is the major effect of a health crisis on family structure? A) Adaptation to stress B) Change in roles of family members C) Respect for family values D) Loss of individual identities

What is the nurse accountable for, according to the state nurse practice act? A) Continuing education B) Nursing diagnoses C) Prescribing medications D) Mentoring other nurses

What safety device for children is mandated by law in all 50 states? A) Bumper pads in baby cribs B) Infant car seats and carriers C) Automatic hot water heater controls D) Parental controls for Internet access

When a charge nurse evaluates the need for additional staff nurses and additional monitoring equipment to meet the client's needs, the charge nurse is performing an evaluation termed ... A) process evaluation B) structure evaluation C) outcome evaluation D) summary evaluation

When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed? A) Complete B) Focused C) General D) Time-lapse

Which client would be most at risk for alterations in oral health? A) Infant who is breast-fed B) Man with a nasogastric tube C) Woman who is pregnant D) Healthy young adult

Which is an example of a closed wound? A) Abrasion B) Ecchymosis C) Incision D) Puncture wound

Which of the following client care concerns is clearly a nursing responsibility? A) Prescribing medications B) Monitoring health status changes C) Ordering diagnostic examinations D) Performing surgical procedures

Which of the following client outcomes best describes the parameters for achieving the outcome? A) The client will eat a well-balanced diet. B) The client will consume a 2,400-calorie diet, with three meals and two snacks, starting tomorrow. C) The client will cleanse his wound with soap and water and apply a dry sterile dressing. D) The client will be without pain in 24 hours.

Which of the following clients would be an appropriate candidate to move by using a powered stand-assist device? A) A comatose client who is being taken for x-rays B) An alert client after knee replacement surgery who is being assisted to ambulate C) An obese client who has Alzheimer's disease and is being escorted to the shower room D) A car accident victim with fractures in both legs who is being moved to another room

Which of the following groups involves all parts of a person's life and is concerned with meeting basic human needs to promote health? A) Peers B) Family C) Community D) Health care providers

Which of the following groups of terms best describes a nurse-initiated intervention? A) Dependent, physician-ordered, recovery B) Autonomous, clinical judgment, client outcomes C) Medical diagnosis, medication administration D) Other health care providers, skill acquisition

Which of the following is a correct guideline to follow when providing a bed bath for a client? A) When cleaning the eye, move the washcloth from the outer to the inner aspect of the eye. B) Fold the washcloth like a mitt on your hand so that there are no loose ends. C) Clean the perineal area before cleaning the gluteal area. D) Change the bath water after washing each body part.

Which of the following is an example of a community factor that may affect health? A) Rural setting B) Air and water quality C) Number of residents D) Educational level

Which of the following is an example of a well-stated nursing intervention? A) Client will drink 100 mL of water every 2 hours while awake. B) Offer client 100 mL of water every 2 hours while awake. C) Offer client water when he complains of thirst. D) Client will continue to increase oral intake when awake.

Which of the following is not appropriate in writing client-centered measurable outcomes? A) The client or a part of the client B) A flexible time frame C) Observable, measurable terms D) The action the client will perform

Which of the following methods of documenting client data is least likely to hold up in court if a case of negligence is brought against a nurse? A) Problem-oriented medical record B) Charting by exception C) PIE charting system D) Focus charting

Which of the following nursing diagnoses would be appropriate for teaching interventions for a single mother who leaves her toddler unattended in the bathtub? A) Noncompliance B) Risk for Suffocation C) Risk for Falls D) Risk for Imbalanced Body Temperature

Which of the following questions or statements would be an appropriate termination of the health history interview? A) "Well, I can't think of anything else to ask you right now." B) "Can you think of anything else you would like to tell me?" C) "I wish you could have remembered more about your illness." D) "Perhaps we can talk again sometime. Goodbye.

Which of the following statements accurately describes a characteristic of a community? A) Communities do not exist in rural areas. B) Communities are formed by the characteristics of people and other factors. C) Communities are not limited by geographic boundaries. D) Communities have little or no effect of the health of residents.

Which of the following statements accurately describes the concepts of disease and illness? A) A disease is traditionally diagnosed and treated by a nurse. B) The focus of nurses is the person with an illness. C) A person with an illness cannot be considered healthy. D) Illness is a normal process that affects level of functioning.

Which statement is true of health care personnel and good hand hygiene? A) Hand hygiene is carefully followed. B) Compliance is difficult to achieve. C) Only nurses need to practice hand hygiene. D) Wearing gloves reduces the need for hand hygiene

While developing the plan of care for a new client on the unit the nurse must identify expected outcomes that are appropriate for the new client. What is a resource for identifying these appropriate outcomes? A) Community Specific Outcomes Classification (CSO) B) The Nursing-Sensitive Outcomes Classification (NOC) C) State Specific Nursing Outcomes Classification (SSNOC) D) Department of Health and Human Resources Outcomes Classification (HHROC)

Why is it important for the nurse to teach and role model proper body mechanics? A) To ensure knowledgeable client care B) To promote health and prevent illness C) To prevent unnecessary insurance claims D) To demonstrate knowledge and skills

Which activity does the nurse perform during the evaluating stage? SELECT ALL THAT APPLY A) Validates with the client the problem of constipation. B) Collects data to determine the number of catheter-associated infections on the nursing unit. C) Increases the frequency of repositioning from every two hours to every one hour. D) Sets a goal of ambulating from bed to room door and back to bed. E) Identifies smoking and sedentary lifestyle as risk factors for hypertension

B C

Which of the following are characteristics of the stage of infection known as full stage of illness? SELECT ALL THAT APPLY A) It is the interval between the pathogen's invasion of the body and the appearance of symptoms of infection. B) Specific signs and symptoms are present. C) The organisms are growing and multiplying. D) The signs and symptoms disappear, and the person returns to a healthy state. E) Early signs and symptoms of disease are present, but these are often vague and nonspecific.

B C

Which of the following statements accurately describes the legal responsibility of the nurse making a diagnosis for a client? A) The nurse may make a diagnosis, but the physician is responsible for making sure it is appropriate for the client. B) The nurse practitioner is responsible for making all nursing diagnoses and determining if they are appropriate for the client. C) The nurse must decide if he or she is qualified to make a nursing diagnosis and will accept responsibility for treating it. D) The health care facility directs the nursing diagnosis in order to receive payment for services performed.

A nurse is assisting a client to shave his beard. Which of the following statements accurately describes a recommended step in this process? A) Cover the client with a blanket. B) Fill a basin with cool water. C) Apply cream to area to be shaved in a layer about 1/2-inch thick. D) Shave against the direction of hair growth in upward, short strokes

A nurse is caring for a client with a serious bacterial infection. The client is dehydrated. Knowledge of the physical effects of the infection would support which of the following nursing diagnoses? A) High Risk for Infection B) Excess Fluid Volume C) Risk for Imbalanced Body Temperature D) Risk for Latex Allergy Response

A nurse is caring for a frail older adult client with chronic obstructive pulmonary disease. The client always remains in a sitting position to help him breathe more easily. Based on the understanding that prolonged sitting may put pressure on bony prominences, the nurse frequently assesses which area of this client? A) Back of the skull B) Elbows C) Sacrum D) Heels

A nurse is caring for a stable toddler diagnosed with accidental poisoning, due to the ingestion of cleaning solution. What must be included in educating parents about how to protect a toddler from accidental poisoning? A) Closely monitor the toddler's activity. B) Label poisonous solutions. C) Keep cleaning solutions locked up. D) Do not leave the toddler alone.

A nurse is changing a sterile pressure ulcer dressing based on an established protocol. What does this mean? A) The nurse is using critical thinking to implement the dressing change. B) The client has specified how the dressing should be changed. C) Written plans are developed that specify nursing activities for this skill. D) The physician verbally requested specific steps of the dressing change

A nurse is collecting information from a client with dementia. The client's daughter accompanies the client. Which of the following statements by the nurse would recognize the client's value as an individual? A) "Can you tell me how long your father has been this way?" B) "Sarah, I have to go and read your father's old charts before we talk." C) "Mr. Koeppe, tell me what you do to take care of yourself." D) "Mr. Koeppe, I know you can't answer my questions, but it's okay."

A nurse is conducting a health history for a client with a skin problem. What question or statement would be most useful in eliciting information about personal hygiene? A) "Perhaps you don't recognize your bad body odor." B) "You must eat a lot of greasy foods to have this acne." C) "Tell me about what you do to take care of your skin." D) "Why do you only take a bath once a week?"

A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, "I have been so constipated lately." How should the nurse respond? A) "Do you have a family history of chest problems?" B) "Why don't you use a laxative every night?" C) "Do you take anything to help your constipation?" D) "Everyone who ages has bowel problems."

A nurse is educating a postoperative client on essential nutrition for healing. What statement by the client would indicate a need for more information? A) "I will drink a lot of orange juice and drink milk, too." B) "I will take the zinc supplement the doctor recommended." C) "I will restrict my diet to fats and carbohydrates." D) "I will drink 8 to 10 glasses of water every day."

A nurse is formulating a nursing diagnosis for a client with a respiratory disease. Which of the following would be correct? A) "needs nasal oxygen to improve breathing" B) "cough related to ineffective airway clearance" C) "ineffective airway clearance related to thick mucus" D) "refuses to cough and expectorate thick mucus"

A nurse is placing a client in Fowler's position. What should she teach the family about this position? A) "Use at least two big pillows to support the head." B) "Cross the arms over the client's abdomen." C) "Do not raise the knees with the knee gatch." D) "Keep the hands lower than the rest of the body."

A nurse is reviewing the health history and physical assessment findings for a client who is having respiratory problems. Of the following data collected, what data from the health history would be a cue to a nursing diagnosis for this problem? A) "I often have diarrhea after I eat spicy foods." B) "My skin is so dry I just can't keep from scratching." C) "I get out of breath when I walk a few steps." D) "I just feel so bad about myself these days."

A nurse is treating the pressure ulcer of an African American client. How would the nurse assess for deep tissue injury in this client? A) Upon inspection the nurse would notice a purple or maroon localized area of discolored, intact skin. B) Upon inspection, the nurse would see a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. C) Upon palpation, the nurse determines that the area preceded by deep tissue injury is painful, firm, boggy, warmer or cooler as compared with adjacent tissue. D) Upon inspection the nurse notes partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.

A nurse makes a medication error and fills out an incident report. What will the nurse do with the incident report once it is filled out? A) Place it in the client's medical record. B) Take it home and keep it locked up. C) Maintain it according to agency policy. D) Include it with documentation of the error.

A nurse performs an assessment of a client in a long-term care facility and records baseline data. The nurse reassesses the client a month later and makes revisions in the plan of care. What type of assessment is the second assessment? A) Comprehensive B) Focused C) Time-lapsed D) Emergency

A nurse provides health promotion and accident prevention programs for a family with adolescents and young adults. Which of the following is a task of a family at this stage? A) Establish a mutually satisfying marriage. B) Adjust to cost of family life. C) Maintain supportive home base. D) Maintain ties with younger and older generations.

While bathing the client, the nurse observes the client grimacing. The nurse asks if the client is experiencing pain. The client nods yes and refuses to continue the bath. The nurse removes the wash basin, makes the client comfortable, and documents the event in the client's chart. Which of the following actions clearly demonstrates assessing? A) The nurse bathing the client B) The nurse documenting the incident C) The nurse asking if the client is having pain D) The nurse removing the wash basin

A nurse performing triage in an emergency room makes assessments of clients using critical thinking skills. Which of the following are critical thinking activities linked to assessment? SELECT ALL THAT APPLY A) Carrying out a physician's order to intubate a client B) Educating a novice nurse on the principles of triage C) Using the nursing process to diagnose a blocked airway D) Interviewing privately a client suspected of being a victim of abuse E) Checking with the family about the data supplied by a client suffering from dementia

C D E

A registered nurse who provides care in a subacute setting is responsible for overseeing and delegating to unlicensed assistive personnel (UAP). Which of the following principles should the nurse follow when delegating to UAP? SELECT ALL THAT APPLY A) Ensure that UAPs closely follow the nursing process when providing care. B) Audit the client documentation that UAPs record after they perform interventions. C) Take frequent mini-reports from UAPs to ensure changes in client status are identified. D) Know what clinical cues the UAP should be alert for and why. E) Make frequent walking rounds to assess clients.

C D E

Which of the following activities is normally acquired in the toddler years? SELECT ALL THAT APPLY A) Rolling over B) Pulling to a standing position C) Walking D) Running E) Jumping

C D E

Which of the following statements accurately describes how risk factors may increase a person's chances for illness or injury? SELECT ALL THAT APPLY A) Risk factors are unrelated to the person or event. B) All risk factors are modifiable. C) An increase in risk factors increases the possibility of illness. D) A family history of breast cancer is not a modifiable risk factor. E) School-aged children are at high risk for communicable diseases.

C D E

An expected client outcome is, The client will remain free of infection by discharge. When evaluating the client's progress, the nurse notes the client's vital signs are within normal limits, the white blood cell count is 12,000, and the client's abdominal wound has a half-inch gap at the lower end with yellow-green discharge. Which statement would be an appropriate evaluation statement? A) Goal partially met; client identified fever and presence of wound discharge. B) Client understands the signs and symptoms of infection. C) Goal partially met; client able to perform activities of daily living. D) Goal not met; white blood cell count elevated, presence of yellow-green discharge from wound.

An woman 80 years of age states, "I have successfully raised my family and had a good life." This statement illustrates meeting which basic human need? A) Safety and security B) Love and belonging C) Self-esteem D) Self-actualization

During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution? A) Document the assessments and intervention. B) Reinforce the dressing with additional layers. C) Administer pain medications intramuscularly. D) Notify the physician and prepare for surgery

A nurse at a health care facility has just reported for duty. Which of the following should the nurse do to ensure maximum efficiency of change-of-shift reports? A) Pay courtesy calls to staff members before attending the meeting. B) Wait for the physicians to arrive before exchanging notes. C) Avoid asking questions related to the medical record. D) Come prepared with material required to take notes.

In what situation would the use of side rails not be considered a restraint? A) The nurse keeps them raised at all times. B) The institution's policies mandate using side rails. C) A visitor requests their use. D) A client requests they be up at night.

Nurses provide many interventions to prevent falls in health care settings. Which of the following would be an appropriate intervention to prevent falls? A) Keep bed in the high position. B) Keep side rails up at all times. C) Apply restraints to all confused clients. D) Lock wheels on beds and wheelchairs.

Nursing students need to learn to nurse themselves in order to prepare to be professional nurses. Which activities would fail to prepare nursing students for the delivery of nursing care? A) Time management, communication, and establishing a support system. B) Establishing a support system, a sense of humor, and self-awareness. C) Self-awareness, preparation for crisis, and stress management. D) A sense of humor, anticipation of loss, and developing negative body image.

A nurse caring for a female client in isolation with tuberculosis is aware that the client's love and belonging needs may not be properly met. Which of the following nursing actions would help to meet these needs? A) Respecting the patient's values and beliefs B) Focusing on the client's strengths rather than problems C) Using hand hygiene and sterile technique to prevent infection D) Encouraging family to visit and help in the care of the client

A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data? A) "My leg hurts so bad. I can't stand it." B) "Appears anxious and frightened." C) "I am so sick; I am about to throw up." D) "Unable to palpate femoral pulse in left leg."

A nurse is ambulating a client who catches her foot on the bed frame and begins to fall. Which of the following is an accurate step to prevent or minimize damage from this fall? A) The nurse should place his or her feet close together with one foot in front of the other. B) The nurse should rock his or her pelvis out on the opposite side of the client. C) The nurse should grasp the gait belt and pull the client's body backward away from his or her body. D) The nurse should gently slide the client down his or her body to the floor.

A nurse is documenting the intensity of a client's pain. What would be the most accurate entry? A) "Client complaining of severe pain." B) "Client appears to be in a lot of pain and is crying." C) "Client states has pain; walking in hall with ease." D) "Client states pain is a 9 on a scale of 1 to 10."

A nurse is educating a rural community group on how to avoid contracting West Nile virus by using approved insect repellant and wearing proper coverings when outdoors. By what means is the pathogen involved in West Nile virus transmitted? A) Direct contact B) Indirect contact C) Airborne route D) Vectors

A nurse is evaluating the outcomes of a plan of care to teach an obese client about the calorie content of foods. What type of outcome is this? A) Psychomotor B) Affective C) Physiologic D) Cognitive

A nurse is manually documenting information related to a client's condition. When documenting this information, the nurse makes an error on the manual record sheet. Which is the best technique for recording the error made in documentation? A) Erase the incorrect statement and write the correct one. B) Cross out the wrong statement in a way that is not readable. C) Use correction fluid to obliterate what has been written. D) Cross out the incorrect statement with a single line.

A nurse is preparing to conduct a health history for a client who is confined to bed. How should the nurse position herself? A) Standing at the end of the bed B) Standing at the side of the bed C) Sitting at least six feet from the beside D) sitting at a 45-degree angle to the bed

A nurse is teaching a client on home care about how to apply hot packs to an infected leg ulcer. What statement by the client indicates the need for further education? A) "I understand the rebound effect of heat." B) "I will put the heat packs only on the sore on my leg." C) "I will only leave the heat packs on for 20 minutes." D) "I will leave the heat packs on for an hour."

A nurse realizes that the dosage of the medication administered to the client has been entered incorrectly into the client records. Which of the following would be most appropriate for the nurse to do? A) Completely erase or delete the erroneous entry if possible. B) Use a highlighter to mark the incorrect entry and place initials next to it. C) Strike out the entry with a single line, place initials next to it, and write the correct entry. D) Black out the erroneous entry with a dark pen or marker.

A physician orders a dressing to cover a wound that is shallow with minimal drainage. What would be the best type of dressing for this wound? A) Saline-moistened dressing B) Dressing secured with Montgomery straps C) Hydrocolloid dressing D) Foam dressing

A student is reviewing a client's chart before giving care. She notes the following diagnoses in the contents of the chart: "appendicitis" and "acute pain." Which of the diagnoses is a medical diagnosis? A) Neither appendicitis nor acute pain B) Both appendicitis and acute pain C) Appendicitis D) Acute pain

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 of the following conditions is likely affecting the client? A) Thrombophlebitis B) Anemia C) Orthostatic hypotension D) Bradycardia

A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during dressing changes. Which response by the nurse is appropriate? A) "Oh, for gosh sakes...it doesn't look that bad!" B) "I understand, but you are going to have to look someday." C) "I respect your wish not to look at it right now." D) "You won't be able to go home until you look at it."

After teaching the students about health and wellness, the nursing instructor identifies a need for further instruction when one of the students makes which of the following statements? A) "Health is more than just the absence of illness." B) "Health is an active process." C) "Health means the same to every person." D) "Health is dynamic and ever-changing."

An experienced nurse is teaching a student nurse the proper use of hand hygiene. Which of the following is an accurate guideline that should be discussed? A) The use of gloves eliminates the need for hand hygiene. B) The use of hand hygiene eliminates the need for gloves. C) Hand hygiene must be performed after contact with inanimate objects near the client. D) Hand lotions should not be used after hand hygiene

An older adult client has edema of the right lower extremity with redness and clear drainage. This is most likely related to what? A) Beta-hemolytic streptococcus B) Age C) Venous insufficiency D) Hemangioma

An woman 80 years of age has had a cerebrovascular accident. She has flaccidity of her right side with aphasia. For this client, which of the following activities constitutes tertiary prevention? A) Assessment of her blood pressure B) Daily bleeding and clotting times C) Gait training and speech therapy D) Education on the symptoms of a CVA

Before a long-term care resident goes to sleep at night, his dentures are placed in a denture cup with clean water. What rationale supports placing dentures in water? A) None; they should be placed in saline B) To increase comfort when replaced in the mouth C) To prevent drying and warping of plastic D) To ensure the dentures are not thrown away

Bioterrorism has become a commonly used term. What is the definition of bioterrorism? A) A verbal threat by those wishing to harm specific individuals B) A written threat calculated to produce terror in a family C) The deliberate spread of pathogens into a community D) A worldwide plan to produce illness and injury

During outcome identification and planning, from what part of the nursing diagnoses are outcomes derived? A) The defining characteristics B) The related factors C) The problem statement D) The database

In addition to identifying responses to actual or potential health problems, what is another purpose of the diagnosing step in the nursing process? A) To collect information about subjective and objective data B) To correlate nursing and medical diagnostic criteria C) To identify etiologies of health problems D) To evaluate mutually developed expected outcomes

Of all possible nursing interventions to break the chain of infection, which is the most effective? A) Administering medications B) Providing good skin care C) Practicing hand hygiene D) Wearing gloves at all times

Of all the benefits of using nursing diagnoses, which one is probably the most important to nurses? A) Defining the domain of nursing practice B) Informing patients of their care C) Improving communication among nurses D) Structuring curricular content

Of the following information collected during a nursing assessment, which are subjective data? A) vomiting, pulse 96 B) respirations 22, blood pressure 130/80 C) nausea, abdominal pain D) pale skin, thick toenails

Of the many topics that may be taught to clients or caregivers about home wound care, which one is the most significant in preventing wound infections? A) Taking medications as prescribed B) Proper intake of food and fluids C) Thorough hand hygiene D) Adequate sleep and rest

The client's pulse oximetry reading is 97% on room air 30 minutes after removal of a nasal cannula. This is an example of what type of outcome? A) Affective outcome B) Psychomotor outcome C) Physiologic outcome D) Cognitive outcome

The facility risk management team is preparing an in-service to nursing staff members. The presentation will highlight risk factor increase related directly to the type of clientele on a nursing unit. The presenter will correctly explain that which of the following risks is increased for female nurses who work on an oncology care unit? A) Back injuries B) Bloodborne pathogens C) Adverse reproduction D) Neurologic disorders

The latest CDC guidelines designate standard precautions for all substances except which of the following? A) Urine B) Blood C) Sweat D) Vomitus

The mother of a child 2 years of age tells the nurse she always cleans the child's ears with a hairpin. What would the nurse tell the mother? A) "That's not good. Use a Q-tip or your finger instead." B) "You really like to keep your child clean. Good for you!" C) "That is dangerous; you might puncture the eardrum." D) "Show me exactly how you use the hairpin."

The nurse and an assistant are preparing to move a client up in bed. Arrange the following steps in the correct order. 1. Adjust the head of the bed to a flat position. 2. Place a friction-reducing sheet under the client. 3. Ask the client to bend legs and place the chin on the chest. 4. Position the assistant on the side opposite you. 5. Remove all pillows from under the client. 6. Grasp the sheet and move the client on the count of 3. A) 3, 1, 2, 4, 5, 6 B) 1, 2, 4, 3, 5, 6 C) 1, 5, 4, 2, 3, 6 D) 3, 2, 1, 4, 6, 5 E) 1, 3, 2, 4, 5, 6

A nurse observes a new mother tenderly holding and softly talking to her baby. What does this observation tell the nurse about the baby's strengths? A) Nothing; this observation is not important. B) The mother is just behaving as all mothers do. C) A baby is not capable of having strengths. D) Nurturing is a strength for developing infants.

A nurse working in long-term care is assessing residents at risk for the development of a decubitus ulcer. Which one would be most at risk? A) A client 83 years of age who is mobile B) A client 92 years of age who uses a walker C) A client 75 years of age who uses a cane D) A client 86 years of age who is bedfast

A nursing diagnosis is written as Disturbed Self-Esteem related to presence of large scar over left side of face. What does the phrase "Disturbed Self-Esteem" identify? A) The expected outcome of the plan of care B) A cue to determining a health problem C) The major defining characteristic of a health problem D) The health state or problem of the client

A student has been assigned to provide hygiene care to four clients. Which one would require special consideration for perineal care? A) Middle-aged man with a nasogastric tube B) Young adult man who has had a hernia repair C) Young woman who has had cosmetic surgery D) Middle-age woman with a Foley catheter

A student has been assigned to provide morning care to a client. The plan of care includes the information that the client requires partial care. What will the student do? A) Provide total physical hygiene, including perineal care. B) Provide total physical hygiene, excluding hair care. C) Provide supplies and orient to the bathroom. D) Provide supplies and assist with hard-to-reach areas

A student identifies Fatigue as a health problem and nursing diagnosis for a client receiving home care for treatment of metastatic cancer. What statement or question would be best to validate this client problem? A) "I have assessed you and find you are fatigued." B) "I analyzed and interpreted your information as fatigue." C) "Why are you so tired all the time?" D) "I think fatigue is a problem for you. Do you agree?"

A student is ambulating a client for the first time after surgery. What would the student do to anticipate and plan for an unexpected outcome? A) Take the client's vital signs after ambulation. B) Ask the client's wife to assist with ambulation. C) Delay ambulation until the following shift. D) Ask another student to help with ambulation.

A student nurse is performing a urinary catheterization for the first time and inadvertently contaminates the catheter by touching the bed linens. What should the nurse do to maintain surgical asepsis for this procedure? A) Nothing, because the client is on antibiotics. B) Complete the procedure and then report what happened. C) Apologize to the client and complete the procedure. D) Gather new sterile supplies and start over

According to Maslow's hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure? A) Ineffective airway clearance B) Ineffective coping C) Impaired urinary elimination D) Risk for body image disturbance

An emergency room nurse is assessing a toddler with multiple bruises and burns. The nurse suspects the toddler has been abused. What is legally required of the nurse? A) Nothing; the nurse has no control over the toddler's home. B) Refer the caregivers of the toddler to a home health nurse. C) Verbally confront the caregivers about the suspicions. D) Report suspicions about the abuse to proper authorities

The nurse formulates the following client outcome: Client will correctly draw up morning dose of insulin and identify four signs and symptoms of hypoglycemia by September 7. Which error has the nurse made? A) Expressed the client outcomes as a nursing intervention B) Wrote vague outcomes that will confuse other nurses C) Included more than one client behavior in the outcome D) Used verbs that are not observable and me

The nurse is caring for a client with a diagnosis of colon disease. The client has expressed to various members of the health care team the desire to be kept comfortable and to not continue further treatment. The client asks the nurse to be present when the client discusses the decision with other family members. In which professional nursing relationship is the nurse participating? A) Nurse-client B) Nurse-nurse C) Nurse-client-family D) Nurse-health care team

The nurse is preparing a client to be turned in bed. In what position would the nurse place the client to begin this procedure? A) Sitting up B) Lying prone C) Lying flat D) Lying flat with feet raised slightly

The nurse is preparing to implement plans of care with several clients. Which action would be inappropriate for the nurse to perform? A) Ask the English-as-a-Second-Language (ESOL) client to state in his or her own words what it means to be NPO. B) Seek input from the family of how the client with aphasia normally communicates at home. C) Respond to the postoperative client's question that baths are given only in the morning. D) Request that family members provide ethnic/cultural foods of the African client's liking.

The nurse is reviewing information about a client and notes the following documentation Client is confused. The nurse recognizes this information is an example of what? A) Subjective data B) A data cue C) An inference D) Primary data

The nurse participates in a quality assurance program. Data from the previous year indicates a 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery. The nurse recognizes this is which type of evaluation? A) Design evaluation B) Process evaluation C) Outcome evaluation D) Structure evaluation

The nursing instructor has given an assignment to a group of nurse practitioner students. They are to break into groups of four and complete a health-promotion teaching project, then present a report back to their fellow students. What project is the best example of health-promotion teaching? A) Demonstrating an injection technique to a client for anticoagulant therapy B) Explaining the side effects of a medication to an adult client C) Discussing the importance of preventing sexually transmitted disease to a group of 12th-grade students D) Instructing an adolescent client about safe food preparation

The staff in a long-term care facility often plays loud rock music on the radio and designs children's games as exercise. What is the staff doing in this situation? A) Considering the hearing level of older adults B) Failing to consider visual deficits that occur with aging C) Ignoring the developmental needs of older adults D) Meeting needs for sensory input and exercise

The wound care clinical nurse specialist has been consulted to evaluate a wound on the leg of a client with diabetes. The wound care nurse determines that damage has occurred to the subcutaneous tissues; how would she document this wound? A) Stage I pressure ulcer B) Stage II pressure ulcer C) Stage III pressure ulcer D) Stage IV pressure ulcer

What activity is carried out during the implementing step of the nursing process? A) Assessments are made to identify human responses to health problems. B) Mutual goals are established and desired client outcomes are determined. C) Planned nursing actions (interventions) are carried out. D) Desired outcomes are evaluated and, if necessary, the plan is modified.

What is the nurse's best defense if a client alleges nursing negligence? A) Testimony of other nurses B) Testimony of expert witnesses C) Client's record D) Client's family

What is the purpose of the affective and coping function of the family? A) Providing a safe environment for growth and development B) Ensuring financial assistance for family members C) Providing emotional comfort and identity D) Transmitting values, attitudes, and beliefs

What may happen to the family when one of the family members suffers an illness? A) Alterations in values and religious beliefs B) More public displays of affection C) Changes in roles for the client and family D) Increased resistance to stress

What name is given to tools that are used to communicate a standardized interdisciplinary plan of care for clients within a case management health care delivery system? A) Kardex care plans B) Computerized plans of care C) Clinical pathways D) Student care planS

What part of the nursing diagnosis statement suggests the nursing interventions to be included in the plan of care? A) Problem statement B) Defining characteristics C) Etiology of the problem D) Outcomes criteria

What role of the nurse is crucial to the prevention of fragmentation of care? A) Advocate B) Educator C) Counselor D) Coordinator

What statement by a client would indicate that a nurse had successfully implemented a educating/learning strategy to prevent injury in the home? A) "I will turn off the outside lights and lock the doors every night." B) "Do you think it would be best for me to buy a gun?" C) "I am going to remove all those throw rugs on the floor." D) "Well, I always let the boys play in the bathtub; they love it."

When assisting a client from the bed into a wheelchair, the nurse assesses the client standing up and notices the client is weak and unsteady. What would be the recommended nursing intervention in this situation? A) Allow the client to keep standing for several minutes until balance returns. B) Use the call bell to summon the assistance of another nurse. C) Return the client to the bed. D) Place the client into the wheelchair.

When educating parents of preschoolers, what is most important to include in your presentation? A) Use wrist guards with rollerblades B) Teach preschoolers to tread water C) Keep chemicals in a locked cabinet D) Strict discipline with potty training

When transferring a client from bed to a stretcher, the nurses working together turn the client to position a transfer board partially underneath the patient. What is the rationale for using a transfer board in this procedure? A) To lift the client off the bed. B) To slide the board with the client onto the stretcher. C) To reduce friction as the client is pulled laterally onto the stretcher. D) To protect the client's head from hitting the headboard

Which is a responsibility of the nurse in the nurse-client-family team relationship? A) Provide creative leadership to make the nursing unit a satisfying and challenging place to work. B) Support the nursing care given by other nursing and non-nursing personnel. C) Educate the family to be informed and assertive consumers of health care. D) Coordinate the inputs of the multidisciplinary team into a comprehensive plan of care

Which of the following data entries follows the recommended guidelines for documenting data? A) "Client is overwhelmed by the diagnosis of pancreatic cancer." B) "Client's kidneys are producing sufficient amount of measured urine." C) "Following oxygen administration, vital signs returned to baseline." D) "Client complained about the quality of the nursing care provided on previous shift"

Which of the following factors may be a barrier to health care services for those living in rural areas? A) Inadequate health care insurance B) Lack of knowledge about needed care C) Living long distances from services D) Decreased interest in health promotion

Which of the following illustrates a common error when writing client outcomes? A) Client will drink 100 mL of fluid every 2 hours from 6 a.m. to 9 p.m. B) Client will demonstrate correct sequence of exercises by next office visit. C) Client will be less anxious and fearful before and after surgery. D) On discharge, client will list five symptoms of infection to report

Which of the following is a correctly written client goal? A) The client will eliminate a soft formed stool. B) The client understands what foods are low in sodium. C) The client will ambulate 10 feet with a walker by October 12. D) The client correctly self-administers the morning dose of insulin.

Which of the following is a tenant of Maslow's basic human needs hierarchy? A) A need that is unmet prompts a person to seek a higher level of wellness. B) A person feels ambivalence when a need is successfully met. C) Certain needs are more basic than others and must be met first. D) People have many needs and should strive to meet them simultaneously.

Which of the following is an example of the body's defense against infection? A) Racial characteristics B) Body shape and size C) Immune response D) Level of susceptibility

Which of the following most accurately defines "illness"? A) The inability to carry out normal activities of living B) A pathologic change in mind or body structure or function C) The response of a person to a disease D) Achieving maximum potential and quality of life

Which of the following most accurately defines an infection? A) An illness resulting from living in an unclean environment B) The result of lack of knowledge about food preparation C) A disease resulting from pathogens in or on the body D) An acute or chronic illness resulting from traumatic injury

Which of the following outcomes is correctly written? A) Abdominal incision will show no signs of infection. B) On discharge, client will be free of infection. C) On discharge, client will be able to list five symptoms of infection. D) During home care, nurse will not observe symptoms of infection

Which of the following questions or statements would be appropriate in eliciting further information when conducting a health history interview? A) "Why didn't you go to the doctor when you began to have this pain?" B) "Are you feeling better now than you did during the night?" C) "Tell me more about what caused your pain." D) "If I were you, I would not wait to get medical help next time."

Successful implementation of each step of the nursing process requires high-level skills in critical thinking. Which of the following statements accurately describe a guideline for using this process? A) Trust clinical judgment and experience over asking for help. B) Respect clinical intuition, but never allow it to determine a diagnosis. C) Recognize personal biases as a strength in formulating diagnoses. D) Keep an open mind and trust your intuition when formulating diagnoses.

The client's expected outcome is The client will maintain skin integrity by discharge. Which of the following measures is best in evaluating the outcome? A) The client's ability to reposition self in bed. B) Pressure-relieving mattress on the bed. C) Percent intake of a diet high in protein. D) Condition of the skin over bony prominences.

The following procedures have been ordered and implemented for a hospitalized client. Which procedure carries the greatest risk for a nosocomial infection? A) Enema B) Intramuscular injections C) Heat lamp D) Urinary catheterization

The nurse assesses urine output following administration of a diuretic. Which step of the nursing process does this nursing action reflect? A) Assessment B) Outcome identification C) Implementation D) Evaluation

The nurse completes a health history and physical assessment on a client who has been admitted to the hospital for surgery. What is the purpose of this initial assessment? A) To gather data about a specific and current health problem B) To identify life-threatening problems that require immediate attention C) To compare and contrast current health status to baseline data D) To establish a database to identify problems and strengths

The nurse is caring for the client with pneumonia. An expected client outcome is, The client will maintain adequate oxygenation by discharge. Which outcome criterion indicates the goal is met? A) Client taking antibiotic as ordered. B) Client identifies signs and symptoms of recurrence of infection. C) Client coughing and deep breathing every one hour. D) Client no longer requires oxygen.

The nurse knows that a health care facility should determine its disaster-preparedness plan for delivering care in the event of an emergency or disaster? A) As soon as the disaster is announced publicly B) When officially informed that a disaster has occurred C) After the first disaster has been experienced D) In advance of a possible emergency or disaster

The nurse overhears two nursing students talking about nursing interventions. Which statement by one of the nursing students indicates further education is required? A) Nursing interventions must be consistent with standards of care and research findings. B) Nursing interventions must be culturally sensitive and individualized for the client. C) Nursing interventions must be compatible with other therapies planned for the client. D) Nursing interventions must be approved by other members of the health care team.

The nurse participates in a quality assurance program and reviews evaluation data for the previous month. Which of the following does the nurse recognize as an example of process evaluation? A) A 10% reduction in the number of ventilator-associated pneumonia B) A 5% increase in the number of nosocomial catheter-related urinary tract infections C) 40% of all client rooms in the facility are private and equipped with a computer D) A nursing care plan was developed within the eight hours of admission for 97% of all admissions.

The nursing student asks the nurse about the difference between family-centered nursing and client-centered nursing. Which of the following would be inappropriate for the nurse to include when responding to the student? A) The family is composed of interdependent members who affect one another. B) The health of the family can be improved through health promotion activities. C) A strong relationship exists between the family and the health status of its members. D) Illness of one family member infrequently occurs in other members.

The nursing student is caring for a Native American client who is admitted for deep vein thrombosis. The nursing student speaks with a nurse regarding the client's lack of eye contact with the student. The nurse responds that Native Americans view eye contact as an invasion of privacy. Which error did the nursing student make? A) Failure to act in partnership with the client. B) Failure to approach the client caringly. C) Failure to seek the client's input in the plan of care. D) Failure to provide culturally sensitive care.

The plan of care for a postoperative client specifies that sterile 0.9% sodium chloride solution be used to clean the wound. What should the nurse do after reading this information? A) Question the physician about the accuracy of this agent. B) Refuse to use 0.9% normal saline on a wound. C) Document the rationale for not changing the dressing. D) Continue with the dressing change as planned

What action by a nurse will help a client meet self-esteem needs? A) Verbally negate the client's negative self-perceptions B) Freely give compliments to increase positive self-regard C) Independently establish goals to improve self-esteem D) Respect the client's values and belief systems

What activity in charting will assist most in the avoidance of errors? A) Objectivity B) Organization C) Legibility D) Timeliness

What are the recommended cleansing agents for hand hygiene in any setting when the risk of infection is high? A) Liquid or bar hand soap B) Cold water C) Hot water D) Antimicrobial products

What are the two major processes involved in the inflammatory phase of wound healing? A) Bleeding is stimulated, epithelial cells are deposited B) Granulation tissue is formed, collagen is deposited C) Collagen is remodeled, avascular scar forms D) Blood clotting is initiated, WBCs move into the wound

What characteristic of a competent nurse practitioner enables nurses to be role models for clients? A) Sense of humor B) Writing ability C) Organizational skills D) Good personal health

What function of the skeletal system is essential to proper function of all other cells and tissues? A) Supporting soft tissues of the body B) Protecting delicate body structures C) Providing storage area for fats D) Producing blood cells

What is the correct rationale for using body substance precautions? A) The risk of transmitting HIV in sputum and urine is nonexistent. B) Disease-specific isolation procedures are adequate protection. C) Only actively infected clients are considered contagious. D) All body substances are considered potentially infectious.

What is the primary purpose of the outcome identification and planning step of the nursing process? A) To collect and analyze data to establish a database B) To interpret and analyze data so as to identify health problems C) To write appropriate client-centered nursing diagnoses D) To design a plan of care for and with the client

What is the primary purpose of validation as a part of assessment? A) To identify data to be validated B) To establish an effective nurse-client communication C) To maintain effective relationships with coworkers D) To plan appropriate nursing care

What nursing diagnosis would be a priority for a client who has a large wound from colon surgery, is obese, and is taking corticosteroid medications? A) Self-care Deficit B) Risk for Imbalanced Nutrition C) Anxiety D) Risk for Infection

What part of the client's record is commonly used to document specific client variables, such as vital signs? A) Progress notes B) Nursing notes C) Critical paths D) Graphic record

When a family visits the counseling clinic for the first time, which of following activities will the nurse complete as part of the initial family assessment? A) Discuss the roles of the parents. B) Outline the basic needs of the family. C) Resolve all family conflicts. D) Interview the family members

When a nursing supervisor evaluates the staff nurse's performance with a group of clients to whom the staff nurse has provided nursing care, the supervisor is performing which type of evaluation? A) Outcome evaluation B) Summary evaluation C) Structure evaluation D) Process evaluation

When providing nursing care to a client, the nurse provides family-centered nursing care. What is one rationale for this nursing action? A) The nurse does not want the client to feel lonely. B) The client will be more compliant with medical instructions. C) The family will be more willing to listen to instructions. D) Illness in one family member affects all family members.

Which clent would be at greatest risk for injury to the skin and mucous membranes? A) Infant 10 days old with no health problems B) adolescent 17 years of age with asthma C) Man 44 years of age with hemorrhoids D) Man 77 years of age with diabetes

Which of the following definitions best describes community-based nursing? A) A focus on populations within the community B) A focus on older adults living in nursing homes C) Care provided in the client's home for chronic illnesses D) care centered on individual and family health care needs

Which of the following factors does not affect personal hygiene practices? A) Culture B) Income level C) Health state D) Gender

Which of the following is a recommended guideline nurses follow when using an electric heating pad on a client? A) Secure the heating pad to the client's clothing with safety pins. B) Place a heavy towel or blanket over the heating pad to maximize heat effects. C) Use a heating pad with a selector switch that can be turned up by the client if needed. D) Place a heating pad anteriorly or laterally to, not under, the body part.

Which of the following is an accurate step when applying a saline-moistened dressing on a client's wound? A) Do not use irrigation to clean the wound before changing the dressing. B) Hold the fine-mesh gauze over the basin and pour the ordered solution over the mesh to saturate it. C) Exert light pressure to pack the wound tightly with moistened dressing. D) Apply several dry, sterile gauze pads over the wet gauze and place the ABD pad over the gauze.

Which of the following is an indication for the use of negative pressure wound therapy? A) Bone infections B) Malignant wounds C) Wounds with fistulas to body cavities D) Pressure ulcers

Which of the following people has the greatest risk for accidental injury? A) An infant just learning to crawl B) An older adult who walks two miles a day C) An athlete who exercises on a regular basis D) A worker who operates industrial machines

Which of the following questions asked by the nurse when taking a client's health history would collect data about infection control? A) Tell me what you eat in each 24-hour period. B) Do you sleep well and wake up feeling healthy? C) What were the causes of death for your family members? D) When did you complete your immunizations?

Which of the following types of care plans is most likely to enable the nurse to take a holistic view of the client's situation? A) Kardex B) Case management C) Critical pathways D) Concept map care plan

Which postural deformity might be assessed in a teenager? A) Kyphosis B) Rickets C) Osteoporosis D) Scoliosis

A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but his care team wishes to now begin introducing minced and pureed food. How should the nurse best position the client? A) Fowler's B) Low-Fowler's C) Protective supine D) Semi-Fowler's

A baby is born with Down syndrome, which influences his health-illness status. This is an example of which of the following human dimensions? A) Physical B) Emotional C) Environmental D) Sociocultural

A camp nurse is teaching a group of adolescent girls about the importance of monthly breast self-examination. What level of preventive care does this activity represent? A) Primary B) Secondary C) Tertiary D) Restorative

The nurse is caring for a client who has been newly diagnosed with diabetes. One of the outcomes the nurse read on the client's plan of care this morning was: "Client will demonstrate correct technique for self-injecting insulin." The client required insulin prior to his lunch and successfully drew up and administered his insulin while the nurse observed. How should the nurse follow up this observation? A) Record an evaluative statement in the client's plan of care. B) Remove the outcome from the client's care plan. C) Ask the nurse who wrote the plan of care to document this development. D) Reassess the client's psychomotor skills at dinner time.

The nurse is caring for a client who has been on bed rest. The primary care provider has just written a new order for the client to sit in the chair three times a day. Which of the following actions will be most effective to transfer the client safely into the chair? A) Have the client sit on the side of the bed for several minutes before moving to the chair. B) Infuse an intravenous fluid bolus 15 minutes before transferring the client into the chair. C) Position a friction-reducing sheet under the client. D) Obtain a quad cane for the client to use as a transfer aid.

The nurse is caring for a client who has prescribed extremity restraints. The nurse is required to document which of the following? A) Alternative measures attempted before applying the restraints B) A verbal order for renewal of the restraints every 48 hours C) Detailed description of the restraint application process D) Type of personal protective equipment (PPE) used by the nurse during restraint application

The nurse is caring for a client with a diagnosis of end-stage renal disease. The client has expressed the desire to be kept comfortable and to not continue further treatment. The daughter arrives from out of town and is demanding to have further testing done to determine the best treatment option for the client. What is the best action for the nurse to take at this time? A) Explain to the daughter the wishes of the client. B) Arrange a meeting between the physician and daughter. C) Contact the imaging center to schedule the testing. D) Persuade the client to agree to the daughter's request

The nurse is conducting a nursing history of a client with a respiratory rate of 30, audible wheezing, and nasal flaring. During the interview, the client denies problems with breathing. What action should the nurse take next? A) Clarify discrepancies of assessment data with the client. B) Validate client data with members of the health care team. C) Document all data collected in the nursing history and physical examination. D) Seek input from family members regarding the client's breathing at home

The nurse is delegating to the unlicensed assistive personnel (UAP). What is the best instruction by the nurse? A) Notify me right away if the client's systolic blood pressure is 170 or greater. B) Let me know if the client's blood pressure becomes elevated. C) If the client's blood pressure falls outside normal limits, come get me. D) I need to know if the client's blood pressure changes from his normal baseline.

The nurse is giving a shift report to the oncoming nurse who will be caring for a client with a portacath access device. The oncoming nurse states, I have never taken care of a client with a portacath. Would you give me the basics, so I know what to do? Which standard for establishing and sustaining healthy work environments is the oncoming nurse breaching? A) Appropriate staffing B) Effective decision making C) True collaboration D) Skilled communication

The nurse is performing a routine assessment of a male client who has an artificial arm as a result of a small plane crash many years earlier. How should the nurse best understand this client's health? A) Despite the loss of his limb, the client may consider himself to be healthy. B) The client may be well, but his loss of limb means that he is unhealthy. C) The loss of his limb prevents the client from achieving wellness, though he may be healthy. D) Because the client's injury is far in the past, it does not have a bearing on his health or wellness.

The nurse is performing an assessment of a client who has a small wound on the knee, collecting cues about the client's health status. Which of the following would the nurse identify as a subjective cue? A) Sharp pain in the knee B) Small bloody drainage on dressing C) Temperature of 102 degrees F D) Pulse rate of 90 beats per minute

The nurse is planning interventions to promote the health of a family struggling with loss of energy and privacy for the parents. In which family stage is the family? A) Family with young children B) Family with adolescents and young adults C) Family with middle-aged adults D) Family with older adults

The nurse is planning the care of a male client who is receiving treatment for acute renal failure and who has begun dialysis three times weekly. The nurse has identified the following outcome: "Client will demonstrate the appropriate care of his arteriovenous fistula." This outcome is classified as which of the following? A) Psychomotor B) Affective C) Cognitive D) Holistic

The nurse is planning to bathe a client who has thigh-high anti-embolism stockings in place. Which of the following actions is correct? A) Remove the anti-embolism stockings during the bath. B) Leave the anti-embolism stockings in place, but be sure to remove all wrinkles. C) Fold the anti-embolism stockings half-way down to allow assessment of the popliteal pulse. D) Leave the anti-embolism stockings in place and spot-clean any soiled areas on the stockings.

The nurse is preparing a care plan for an African American man age 68 years who was recently diagnosed with hypertension. Age, race, gender, and genetic inheritance are examples of what human dimension? A) Physical B) Emotional C) Environmental D) Sociocultural

The nurse is preparing to mail a client satisfaction questionnaire to a client who was discharged from the hospital four days ago. Which type of evaluation is the nurse conducting? A) Retrospective evaluation B) Peer review C) Nursing audit D) Concurrent evaluation

The nurse is preparing to move a client from bed into a wheelchair to eat lunch. What client data would the nurse check to see if the assistance of another nurse is needed? A) Client restrictions B) Client age C) Client food preferences D) Client restraints

What age group is most vulnerable to toxic fumes or asphyxiation? A) Young children B) Adolescents C) Toung adults D) Middle adults

The nurse is preparing to perform perineal care on an uncircumcised adult male client who was incontinent of stool. The client's entire perineal area is heavily soiled. Which of the following techniques for cleaning the penis is correct? A) Retract the foreskin while washing the penis; then, immediately pull the foreskin back into place. B) Retract the foreskin while washing the penis, allow 10 to 15 minutes for the glans penis to dry; then, replace the foreskin in its original position. C) Avoid retraction of the foreskin because injury and scarring could occur. D) Soak the end of the penis in warm water before cleaning the shaft of the penis.

The nurse is reviewing a client's chart. When reading the history, physical, and physician progress notes, the nurse anticipates finding which of the following? A) The physician's assessment and treatment B) Results of laboratory and diagnostic studies C) Nursing documentation and plan of care D) Information from other members of the health care team

The nurse is using a systematic approach to the collection of assessment data. The nurse uses an assessment guide that uses a hierarchy of five life requirements universal to all persons. What model for organizing the assessment data is the nurse using? A) Human Needs (Maslow) model B) Functional Health Patterns model C) Human Response Patterns model D) Body System model

The nurse managers of a home health care office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal? A) Narrative notes B) SOAP notes C) Focus charting D) Charting by exception

The nurse notes that the blood glucose level of a client has increased and is planning to notify the health care provider by telephone. Which of the following techniques would be most appropriate for the nurse to use when communicating with the health care provider? A) ISBAR B) EMAR C) SOAP D) CBE

The nurse observes the client as he walks into the room. What information will this provide the nurse? A) Information regarding the client's gait B) Information regarding the client's personality C) Information regarding the client's psychosocial status D) Information on the rate of recovery from surgery

The nurse should utilize ISBARR communication (Introduction, Situation, Background, Assessment, Recommendation, Read Back) during which of the following clinical situations? A) When communicating a client's change in condition to the client's physician B) When providing a change-of-shift report to a colleague C) When documenting the care that was provided to a client whose condition recently deteriorated D) When reporting to a client's family member or significant other

The nurse who is caring for a child admitted after an automobile accident recognizes the importance of including the child's family in the plan of care. Inclusion of the family meets which of Maslow's basic human needs? A) Love and belonging B) Physiologic C) Self-esteem D) Self-actualization

The nurse witnessed a more senior nurse make six unsuccessful attempts at starting an intravenous (IV) line on a client. The senior nurse persisted, stating, "I refuse to admit defeat." This resulted in unnecessary pain for the client. How should the first nurse best respond to this colleague's incompetent practice? A) Report the nurse's practice and have the nurse manager address the matter. B) Encourage the nurse to attend an in-service on IV starts. C) Reassure the nurse that this is a difficult skill and give her feedback on her performance. D) Document an unmet outcome in the client's plan of care.

The nurse would recognize which of these devices as an open drainage system? A) Penrose drain B) Jackson-Pratt drain C) Hemovac D) Negative pressure dressing

The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which of the following drawbacks? A) Vulnerability to legal liability since nurse's safe, routine care is not recorded B) Increased workload for nurses in order to complete necessary documentation C) Failure to identify and record client problems and associated interventions D) Significant differences in the charting between nurses due to lack of standardization

The nursing diagnosis Impaired Gas Exchange, prioritized by Maslow's hierarchy of basic human needs, is appropriate for what level of needs? A) Physiologic B) Safety C) Love and belonging D) Self-actualization

The nursing student is assessing a community in regard to safety and security. Which of the following would be inappropriate for the nursing student to include under this basic need category? A) Parks and swimming pools B) Police and fire departments C) Sanitation facilities D) Housing and zoning codes

The physician's admitting orders indicate that the client is to be placed in a Fowler's position. Upon positioning this client, how much will the nurse elevate the head of the bed? A) 45 to 60 degrees B) 15 to 20 degrees C) 30 degrees D) 90 degrees

Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue easily bleeds when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment? A) Proliferation phase B) Hemostasis C) Inflammatory phase D) Maturation phase

Upon evaluation of the client's plan of care, the nurse determines that the expected outcomes have been achieved. Based upon this response, the nurse will do what? A) Terminate the plan of care. B) Modify the plan of care. C) Continue the plan of care. D) Re-evaluate the plan of care.

Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. Initial nursing management includes calling the physician and doing which of the following? A) Covering the wound area with sterile towels moistened with sterile 0.9% saline B) Closing the wound area with Steri-Strips C) Pouring sterile hydrogen peroxide into the abdominal cavity and packing with gauze D) Holding the wound together until the physician arrives

Upon review of the client's orders, the nurse notes that the client was recently started on an anticoagulant. What is an appropriate consideration when assisting the client with morning hygiene? A) Provide the client with an electric shaver. B) Provide the client with a firm bristled toothbrush. C) Do not allow the client to shower. D) Avoid massaging the client's back with lotion

Which of the following examples of client data needs to be validated? SELECT ALL THAT APPLY A) A client has trouble reading an informed consent, but states he does not need glasses. B) An elderly client explains that the black and blue marks on his arms and legs are due to a fall. C) A nurse examining a client with a respiratory infection documents fever and chills. D) A client in a nursing home states that she is unable to eat the food being served. E) A pregnant client is experiencing contractions that are two minutes apart

A B

A nurse specializes in caring for victims of domestic violence. Which of the following statements accurately describes domestic violence in the United States? SELECT ALL THAT APPLY A) Studies indicate that each year, more than 12 million adults in the United States are victims of intimate partner violence. B) Intimate partner violence is domestic violence or battering between two people in a close relationship. C) Many men who batter their spouses also batter their children. D) There is no evidence linking childhood sexual abuse to adult physical symptoms or substance abuse. E) Domestic violence is not seen in a cycle

A B C

An older adult male client is admitted to the cardiac ICU after suffering a heart attack. Upon taking a history after the client is stable, the nurse charts that he weighs over 275 pounds, has a history of heart disease in his family, suffers frequent stress at work, drinks alcohol daily, and smokes two packs of cigarettes daily. What are some modifiable risks factors for this client that has attributed to his heart attack? SELECT ALL THAT APPLY A) Alcohol intake B) Smoking C) Stress D) Age E) Family history F) Sex

A B C

Which activity does the nurse engage in during evaluation? SELECT ALL THAT APPLY A) Collect data to determine whether desired outcomes are met. B) Assess the effectiveness of planned strategies. C) Adjust the time frame to achieve the desired outcomes. D) Involve the client and family in formulating desired outcomes. E) Initiate activities to achieve the desired outcomes.

A B C

Which client outcome is a physiologic outcome? SELECT ALL THAT APPLY A) The client's HA1c is 7.4%. B) The client's blood pressure is 118/74. C) The client rates his or her pain rating as 6. D) The client self-administers insulin subcutaneously. E) The client describes manifestations of wound infection.

A B C

The nurse is assessing the functions of a family. Which items are functions of the family? SELECT ALL THAT APPLY A) Provide a safe, comfortable home in which to reside. B) Communicate cultural values and beliefs to family members. C) Provide emotional support to family members. D) Secure adequate income to meet the needs of the family. E) Make referrals to community-based healthcare resources

A B C D

Which of the following clients is at an increased risk for oral problems? SELECT ALL THAT APPLY A) Comatose client B) Confused client C) Depressed client D) Client undergoing chemotherapy E) Hypertensive client

A B C D

Which of the following are functions of the skin? SELECT ALL THAT APPLY A) Protection B) Temperature regulation C) Sensation D) Vitamin C production E) Immunological

A B C E

Which of the following statements explains why models of health promotion and illness prevention are useful when planning health care? SELECT ALL THAT APPLY A) They help health care providers understand health-related behaviors. B) They are useful for adapting care to people from diverse backgrounds. C) They help overcome barriers related to increased number of people without health care. D) They overcome barriers to care for the predicted downward trend in minority populations. E) They overcome barriers to care for low-income and rural populations

A B C E

Which of the following are examples of breaches of client confidentiality? SELECT ALL THAT APPLY A) A nurse discusses a client with a coworker in the elevator. B) A nurse shares her computer password with a relative of a client. C) A nurse checks the medical record of a client to see who should be called in an emergency. D) A nurse updates the employer of a client regarding the client's return to work. E) A nurse uses a computer to document a client's response to pain medication

A B D

A nurse is applying cold therapy to a client with a contusion of the arm. Which of the following is an effect of cold therapy? SELECT ALL THAT APPLY A) Constricts peripheral blood vessels B) Reduces muscle spasms C) Increases blood flow to tissues D) Increases the local release of pain-producing substances E) Reduces the formation of edema and inflammation

A B E

A nurse is giving a talk to a local community group on health promotion and illness prevention. The nurse explains the different levels of promotion. Which of the following does the nurse include when talking about primary promotion? SELECT ALL THAT APPLY A) Immunization clinics B) Poison control information C) Screenings for blood pressure D) Recommending mammograms for women E) Teaching about a healthy diet

A B E

Which of the following abbreviations is on the list of the Joint Commission do not use abbreviations? SELECT ALL THAT APPLY A) U (unit) B) QD (daily) C) NPO (nothing per os) D) mL (milliliters) E) > (greater than)

A B E

A nurse inspecting a client's pressure ulcer documents the following: full-thickness tissue loss; visible subcutaneous fat; bone, tendon, and muscle are not exposed. This pressure ulcer is categorized to be at which of the following stages? A) Stage I B) Stage II C) Stage III D) Stage IV

A physician's order reads "up ad lib." What does this mean in terms of client activity? A) May walk twice a day B) May be up as desired C) May only go to the bathroom D) Must remain on bed rest

A boy age 2 years arrives at the emergency department of a local hospital with difficulty breathing from an asthmatic attack. Which of the following would be the priority nursing intervention? A) Giving him his favorite stuffed animal to hold B) Assessing respirations and administering oxygen C) Raising the side rails and restraining his arms D) Asking his mother what are his favorite foods

A client age 78 years with diabetes needs to have his toenails trimmed. It is important for the nurse to do what? A) Remove ingrown toenails B) Cut the nail straight across C) Protect the foot from blisters D) Soak the foot in witch hazel

A client comes to her health care provider's office because she is having abdominal pain. She has been seen for this problem before. What type of assessment would the nurse do? A) Initial assessment B) Focused assessment C) Emergency assessment D) Time-lapsed assessment

A client complains to the nurse-in-charge about another nurse on night shift. The client says that he kept calling the nurse but she never responded. Further, when he questioned the nurse, she said that she had other patients to take care of. The nurse-in-charge is aware that the client can be very demanding. What is an appropriate response for the nurse? A) "I am sorry that you had to suffer this way. The nurse on night duty should be fired." B) "It's hard to be in bed and ask for help. You ring for a nurse who never seems to help." C) "You seem to be impatient. The nurses work very hard and they do whatever they can." D) "I can see that you are angry. What the nurse did is wrong, and it won't happen again

A client has an external fixation device on his leg due to a compound fracture. The client says that the device and swelling makes his leg look ugly. Which nursing diagnosis should the nurse document in his care plan based on the client's concern? A) Impaired physical mobility B) Disturbed body image C) Risk for infection D) Risk for social isolation

A client is admitted to the hospital with abrupt symptoms of increasing shortness of breath, fever, and a productive cough with green sputum. Upon further exam the client is diagnosed with chronic obstructive pulmonary disease (COPD) exacerbation. The nurse identifies this as which type of illness? A) Acute B) Chronic C) Terminal D) Contagious

A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital signs. Which of the following data collected can be classified as subjective data? A) Blood pressure B) Nausea C) Heart rate D) Respiratory rate

A client is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the client states, "I am very nervous and scared to have surgery." What client outcome is the priority? A) Evaluate the need for antibiotics. B) Resolve the client's anxiety. C) Provide preoperative education. D) Prepare the client for surgery.

A client who has had abdominal surgery develops an infection in the wound while still hospitalized. Which of the following agents is most likely the cause of the infection? A) Virus B) Bacteria C) Fungi D) Spores

A college-aged student has influenza. At what stage of the infection is the student most infectious? A) Incubation period B) Prodromal stage C) Full stage of illness D) Convalescent period

A grade school nurse is addressing parents at a PTA meeting regarding car safety. Which of the following is a recommended safety guideline for this age group? A) All school-age children need to be secured in safety seats. B) Booster seats should be used for children until they are 4 feet 9 inches tall or at least 8 years of age. C) Children under 8 years old should ride in the back seat. D) All school-age children need to be secured in lap seat belts

A middle-aged woman is 40 pounds over her ideal weight. Which of the following statements best illustrates the effect of her self-concept on health and illness? A) "I am just too busy with my kids to bother about a diet." B) "Why should I lose weight? I'll still be fat." C) "My sister is thin, but I don't think she looks that good." D) "My husband loves me this way."

A nurse calls in to his unit to report he has the flu and will not be at work. What stage of illness behavior is he exhibiting? A) Experiencing symptoms B) Assuming the sick role C) Assuming a dependent role D) Achieving recovery and rehabilitation

A nurse caring for a client admitted to the intensive care unit with a stroke assesses the client's vital signs, pupils, and orientation every few minutes. The nurse is performing which type of assessment? A) Initial assessment B) Focused assessment C) Time-lapsed reassessment D) Emergency assessment

A nurse caring for a female client notes a number of laceration wounds around the cervix of the uterus due to childbirth. How could the nurse describe the laceration wound in the client's medical record? A) A clean separation of skin and tissue with a smooth, even edge B) A separation of skin and tissue in which the edges are torn and irregular C) A wound in which the surface layers of skin are scraped away D) A shallow crater in which skin or mucous membrane is missing

A nurse caring for an older adult client in a long-term care facility notices that the bedding is wet when the client gets up in the morning. The nurse collects more data to form a conclusion. What type of problem is involved in this scenario? A) No problem B) Possible problem C) Actual problem D) Clinical problem

A nurse forgets to raise the bed railings of a client who is confused after taking pain medications. The client attempts to get out of bed, and suffers a minor fall. The nurse asks a colleague who witnessed the fall not to mention it to anyone because the client only had minor bruises. What would be the appropriate action of the colleague? A) No other steps need to be taken, since the client was not seriously injured. B) The colleague should inform the nurse that a full report of the incident needs to be made. C) The colleague should monitor the client closely for any adverse effects of the fall. D) The colleague should report the incident in a peer review of the nurse

A nurse has developed a plan of care with nursing interventions designed to meet specific client outcomes. The outcomes are not met by the time specified in the plan. What should the nurse do now in terms of evaluation? A) Continue to follow the written plan of care. B) Make recommendations for revising the plan of care. C) Ask another health care professional to design a plan of care. D) State "goal will be met at a later date."

A nurse is assisting in the transfer of a client to a stretcher. The client has casts on both legs. What is the nurse's best choice of transfer equipment for this client who cannot bear weight on either leg? A) Powered-stand assist B) Transfer chair C) Repositioning lift D) Gait belt

A nurse is caring for a client who is in the remission state of leukemia. The client expresses anxiety about the recurrence of leukemia. The client feels depressed when thinking about the outcome of leukemia. Which aspect of health is the client talking about? A) Physical health B) Emotional health C) Social health D) Spiritual health

A nurse is caring for a client who is two days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time? A) Administer pain medications on a p.r.n. and regular basis. B) Assist in moving to prevent strain on the suture line. C) Tell the client that a mild fever is a normal response. D) If a scar forms over a joint, it may limit movement

A nurse is collecting data from a home care client. In addition to information about the client's health status, what is another observation the nurse should make? A) Number of rooms in the house B) Safety of the immediate environment C) Frequency of home visits to be made D) Friendliness of the client and family

A nurse is developing outcomes for a specific problem statement. What is one of the most important considerations the nurse should have? A) The written outcomes are designed to meet nursing goals B) To encourage the client and family to be involved C) To discourage additions by other healthcare providers D) Why the nurse believes the outcome is important

A nurse is discharging a client from the hospital. When should discharge planning be initiated? A) At the time of discharge from an acute health care setting B) At the time of admission to an acute health care setting C) Before admission to an acute health care setting D) When the client is at home after acute care

A nurse is documenting client information using PIE charting. Which information would the nurse expect to document? A) Client assessment B) Intervention carried out C) Written plan of care D) Multidisciplinary interventions

A nurse is documenting information about a client in a long-term care facility. What is used in a Medicare-certified facility as a comprehensive assessment and as the foundation for the Resident Assessment Instrument (RAI)? A) PIE system B) Minimum data set C) OASIS D) Charting by exception

A nurse is educating a client on how to administer insulin, with the expected outcome that the client will be able to self administer the insulin injection. How would this outcome be evaluated? A) Asking the client to verbally repeat the steps of the injection B) Asking the client to demonstrate self-injection of insulin C) Asking family members how much trouble the client is having with injections D) Asking the client how comfortable he or she is with injections

A nurse is educating adolescents on how to prevent infections. What statement by one of the adolescents indicates that more education is needed? A) "I will wash my hands before and after going to the bathroom." B) "I don't wear a condom when I have sex, but I know my partners." C) "I always eat fruits and vegetables, and I sleep eight hours a night." D) "When I have an infection, I rest and take my medications."

A nurse is preparing to insert an intravenous line and begin administering intravenous fluids. The client has visitors in the room. What should the nurse do? A) Ask the visitors to leave the room. B) Ask the client if visitors should remain in the room. C) Tell the client to ask the visitors to leave the room. D) Wait until the visitors leave to begin the procedure.

A nurse is providing oral care to a client with dentures. What action would the nurse do first? A) Assess the mouth and gums. B) Don gloves. C) Wash the client's face. D) Apply lubricant.

A nurse is repositioning a client who has physical limitations due to recent back surgery. How often would the nurse turn the client in bed? A) Every hour B) Every two hours C) Every four hours D) Every shift

A nurse is required to clean the open wounds of a client who has been involved in an automobile accident. What intervention would the nurse need to perform when cleaning open wounds to protect himself from infection? A) Wash hands with alcohol-based hand wash. B) Wear a pair of sterile latex gloves. C) Use sterilizing acid to clean the injury. D) Use sterile solutions such as normal saline.

A nursing home recently has had a significant number of nosocomial infections. Which of the following measures might be instituted to decrease this trend? A) Mandating antibiotics for all nursing home residents B) Have written, infection-prevention practices for all employees C) Requiring all employees to have monthly screenings for skin flora D) Restricting visitors and community activities for residents

A physician orders restraints for a confused client who is at risk for injury by pulling out tubes necessary to sustain her life. Which of the following statements describes an accurate action to take when applying these restraints? A) Apply restraints to the hands or wrists, never to the ankles. B) Ensure that two fingers can be inserted between the restraint and the client's extremity. C) Use a quick-release knot to tie the restraint to the side rail. D) Remove the restraint at least every four hours, or according to agency policy.

A nurse is counseling a novice nurse who gives 150% effort at all times and is becoming frustrated with a health care system that provides substandard care to clients. Which of the following advice would be appropriate in this situation? SELECT ALL THAT APPLY A) Tell the new nurse to help other nurses perform their jobs, thus ensuring quality client care is being delivered. B) Encourage the new nurse to leave her problems at work behind, instead of rehashing them at home. C) After establishing a reputation for delivering quality nursing care, have her seek creative solutions for nursing problems. D) Tell her to view nursing care concerns as challenges rather than overwhelming obstacles, and seek help for solutions. E) State that if resources do not permit quality care, it is not the role of the new nurse to explore change strategies within the institution.

B C D

Nurses identifying outcomes and related nursing interventions must refer to the standards and agency policies for setting priorities, identifying and recording expected client outcomes, selecting evidence-based nursing interventions, and recording the plan of care. Which of the following are recognized standards? SELECT ALL THAT APPLY A) Professional physicians' organizations B) State Nurse Practice Acts C) The Joint Commission D) The Agency for Health Care Research and Quality E) The Patient Health Partnership

B C D

The nurse is providing care for a client who experienced an ischemic stroke five days ago. Which of the following diagnoses would the nurse be justified in identifying and documenting in the care of this client? SELECT ALL THAT APPLY A) Dysphagia B) Bowel Incontinence C) Impaired Swallowing D) Impaired Physical Mobility E) Risk for Hemiparesis

B C D

In which of the following cases should a progress note be written? SELECT ALL THAT APPLY A) For any nurse-client interaction B) When admitting a client C) When receiving a client postoperatively D) When assisting a client with ADLs E) When a procedure is performed

B C E

Which of the following statements accurately describes a recommended guideline for implementation? SELECT ALL THAT APPLY A) When implementing nursing care, remember to act independently, regardless of the wishes of the client/family. B) Before implementing any nursing action, reassess the client to determine whether the action is still needed. C) Assume that the nursing intervention selected is the best of all possible alternatives. D) Consult colleagues and the nursing and related literature to see if other approaches might be more successful. E) Reduce your repertoire of skilled nursing interventions to ensure a greater likelihood of success.

B D

A nurse in a nursing home is writing a note that addresses the care a resident has received during the day and the resident's response to care. What type of note does this represent? A) PIE note B) Flow sheet C) Narrative note D) SOAP note

A cleint accepts the fact that he needs bypass surgery for a blocked artery and is admitted into the hospital. Which one of the following stages of illness is this client experiencing? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4

A client comes to the emergency department with major burns over 40% of his body. Although all of the following are true, which one would provide the rationale for a nursing diagnosis of Risk for Infection? A) Stress may adversely affect normal defense mechanisms. B) White blood cells provide resistance to certain pathogens. C) Intact skin and mucous membranes protect against microbial invasion. D) Age, race, sex, and hereditary factors influence susceptibility to infection

A client states, "I must be in poor health because I am a senior citizen. That's what my neighbor says and she is older than I am." This statement is based on which of the following factors? A) Age B) Gender C) Peer influence D) Illness factors

A client who has to undergo a parathyroidectomy is worried that he may have to wear a scarf around his neck after surgery. What nursing diagnosis should the nurse document in the care plan? A) Risk for impaired physical mobility due to surgery B) Ineffective denial related to poor coping mechanisms C) Disturbed body image related to the incision scar D) Risk of injury related to surgical outcomes

A couple recently married. Both the husband and the wife have previously been married and had two children. What name is given to this type of family? A) Extended family B) Nuclear family C) Blended family D) Cohabiting family

A female client in a reproductive health clinic tells the nurse practitioner that she douches every day. Should the nurse tell the client to continue this practice? A) Yes, this helps prevent vaginal odor. B) Yes, this decreases vaginal secretions. C) No, douching removes normal bacteria. D) No, douching may increase secretions

A man 75 years of age is being discharged to his home following a fall in his kitchen that resulted in a fractured pelvis. The home health nurse makes a home assessment that will be used to design interventions to meet which priority need? A) Sleep and rest B) Support from family members C) Protection from potential harm D) Feeling a sense of accomplishment

A newly hired nurse is participating in the orientation program for the health care facility. Part of the orientation focuses on the use of the SOAP (subjective, objective, assessment, and plan) method for documentation, which the facility uses. The nurse demonstrates understanding of this method by identifying which of the following as the first step? A) Plan of care B) Data, action, and response C) Problem selected D) Nursing activities during a shift

A nurse caring for a client who has gas gangrene knows that this infection originated in which of the following reservoirs? A) Other people B) Food C) Soil D) Animals

A nurse caring for a post-operative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as which of the following? A) Serous B) Sanguineous C) Serosanguineous D) Purulent

A nurse delegates a specific intervention to a UAP. What implications does this have for the nurse? A) The UAP is responsible and accountable for his or her own actions. B) Nurses do not have authority to delegate interventions. C) The nurse transfers responsibility but is accountable for the outcome. D) The UAP can function in an independent role for all interventions.

A nurse develops a plan of care to meet the needs of a client who has had a large loss of blood after a snowmobile crash. Intravenous fluids and blood are administered and the nurse monitors the client's physiologic response. This action is known as a: A) medical diagnosis. B) nursing diagnosis C) collaborative problem. D) goal for care.

A nurse enters a client's room and finds that the client has fallen on her way to the bathroom. Which of the following is a prudent nursing intervention for this client? A) Briefly leave the client in order to call the primary physician to assess the client's condition. B) Order x-rays or CT scans for the client, as needed. C) Document the incident, assessment, and interventions in the client's medical record. D) Do not file an event report unless the client is seriously injured in the fall.

A nurse has access to computerized standardized plans of care. After printing one for a client, what must be done next? A) Date it and put it in the client's record. B) Sign it and put it in the Kardex. C) Individualize it to the specific client. D) Use it as printed, based on common needs

A nurse has completed morning care for a client. There is no visible soiling on her hands. What type of technique is recommended by the CDC for hand hygiene? A) Do not wash hands, apply clean gloves. B) Wash hands with soap and water. C) Clean hands with an alcohol-based handrub. D) Wash hands with soap and water, follow with handrub.

A group of nurses visits selected clients individually at the beginning of each shift. What are these procedures called? A) Nursing care conferences B) Staff visits C) Interdisciplinary referrals D) Nursing care rounds

A home health nurse has a caseload of several postoperative clients. Which one would be most likely to require a longer period of care? A) An infant B) A young adult C) A middle adult D) An older adult

A man on an airplane is sitting by a woman who is coughing and sneezing. If she has an infection, what is the most likely means of transmission from the woman to the man? A) Direct contact B) Indirect contact C) Vectors D) Airborne route

A mother teaches her son to respect his elders. This is an example of which of the following family functions? A) Physical B) Economic C) Affective and coping D) Socialization

A nurse administers a medication for pain but forgets to document it in the client's medical record. Legally, what does this mean? A) Nothing, the nurse's honesty will not be questioned. B) The nurse can add the documentation after the client goes home. C) The physician will verify that the nurse carried out the order. D) In the eyes of the law, if it is not documented, it was not done.

A nurse assessing a client's wound documents the finding of purulent drainage. What is the composition of this type of drainage? A) Clear, watery blood B) Large numbers of red blood cells C) Mixture of serum and red blood cells D) White blood cells, debris, bacteria

A child age 4 years has leukemia but is now in remission. What does it mean to be in remission when one has a chronic illness? A) The chronic disease has been cured. B) Nothing further can be done in terms of treatment. C) Severe symptoms of the chronic illness have reappeared. D) The disease is present, but symptoms are not experienced.

A client is admitted to the health care facility with a diagnosis of pediculosis capitis. Which of the following would the nurse expect to find in the client? A) Diffuse scaling of the epidermis B) Itching and flaking of whitish scales C) Premature loss of hair D) Inflammation related to bites along the hairline

A client is experiencing shortness of breath, lethargy, and cyanosis. These three cues provide organization or ... A) Categorizing B) Diagnosing C) Grouping D) Clustering

A client is very anxious and states, "I am so stressed." Why do these factors affect the client's safety? A) Stress increases retention of information B) Stress affects interpersonal relationships C) Stress increases concern about hazards D) Stress tends to narrow the attention span

A client who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes an order to increase oral intake. Why would the nurse review the plan of care? A) To implement evidence-based practice B) To ensure the order follows hospital policy C) To be sure interventions are individualized D) To be sure the intervention is safe

A doctor orders restraints for an older adult client who is disoriented from the pain medication she is taking. Which of the following is an appropriate guideline for applying these restraints? A) Chemical restraints should be tried before using physical restraints. B) The restraints can be ordered by the nursing supervisor in emergency situations. C) The client's vital signs must be assessed every hour. D) Adults must be reassessed within 4 hours; children age 9 to 17 years within two hours; and children under 9 years within one hour.

The nurse is caring for a client who is experiencing an asthma attack. Ten minutes after administering an inhaled bronchodilator to the client, the nurse returns to ask if the client's breathing is easier. The nurse is engaging in which phase of the nursing process? A) Assessment B) Diagnosing C) Planning D) Implementing E) Evaluating

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