Fundamentals pt. 2: Basics of nursing & Physiological Aspects of Care

Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus?

Impaired neural functioning

The nurse is caring for a client who is receiving therapy for vitamin B 12 deficiency. Which finding indicates that the therapy is having the desired effect?

Improved hemoglobin and hematocrit levels

As a nurse prepares an older adult client for sleep, actions are taken to help reduce the likelihood of a fall during the night. What nursing action is most appropriate when targeting older adults' most frequent cause of falls?

Instructing the client to call the nurse before going to the bathroom.

A nurse is preparing to change a client's dressing. What is the reason for using surgical asepsis during this procedure?

Keeps the area free of microorganisms.

A nurse applies an ice pack to a client's leg for 20 minutes. The cold application will cause what physiological effect?

Local anesthesia

A nurse is helping a client who observes the traditional Jewish dietary laws to prepare a dietary menu. What considerations should the nurse make?

Meat and milk at the same meal are forbidden.

A pain scale of 1 to 10 is used by a nurse to assess a client's degree of pain. The client rates the pain as an 8 before receiving an analgesic and a 7 after being medicated. What conclusion should the nurse make regarding the client's response to pain medication?

Medication is not adequately effective.

A nurse is caring for an elderly client who has constipation. Which independent nursing intervention helps to reestablish normal bowel pattern?

Offer a cup of prune juice.

A client is admitted for surgery. Although not physically distressed, the client appears apprehensive and withdrawn. What is the nurse's best action?

Orient the client to the unit environment.

The nurse should monitor for which involuntary physiological response in a client who is experiencing pain?

Perspiring

A 90-year-old female resident of a nursing home falls and fractures the proximal end of her right femur. The surgeon plans to reduce the fracture with an internal fixation device. The general fact about the older adult that the nurse should consider when caring for this client is that:

Physiological coping defenses are reduced

A client had extensive, prolonged surgery. Which electrolyte level should the nurse monitor most closely?

Potassium

When a client files a lawsuit against a nurse for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. This is known as:

Proximate cause

The nurse is preparing to assess the four abdominal quadrants of a client who complains of stomach pain. When determining the order of the assessment, the nurse recognizes that it is important to assess the symptomatic quadrant:

last

Several recently licensed practical nurses are discussing whether they should purchase personal professional liability insurance. Which statement indicates the most accurate information about professional liability insurance?

"Personal liability insurance offers representation if the State Board of Nursing files charges against you."

What is a nurse's most appropriate response, based on current research, when asked about spanking as a disciplinary technique?

"Spanking is strongly suggestive of negative role modeling."

A nurse provides discharge teaching related to intermittent urinary self-catheterization to a client with a new spinal cord injury. Which instruction is most important for the nurse to include?

"Wash your hands before performing the procedure."

A client with arthritis increases the dose of ibuprofen (Motrin, Advil) to abate joint discomfort. After several weeks the client becomes increasingly weak. The client is admitted to the hospital and is diagnosed with severe anemia. What clinical indicators does the nurse expect to identify when performing an admission assessment? (SATA)

-Melena -Tachycardia

A nurse suspects that a client has poison ivy. Assessment findings reveal vesicles on the arms and legs. A vesicle can be described as:

A lesion filled with serous fluid.

A dying client is coping with feelings regarding impending death. The nurse bases care on the theory of death and dying by Kübler-Ross. During which stage of grieving should the nurse primarily use nonverbal interventions?

Acceptance

A nurse discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a history of alcoholism. What need must self-help groups such as AA meet to be successful?

Belonging

The nurse instructs a client with a new colostomy to avoid foods and drinks that produce a large amount of gas, and specifically to avoid the intake of:

Cabbage

A nurse applies a cold pack to treat an acute musculoskeletal injury. Cold therapy decreases pain by:

Causing local vasoconstriction, preventing edema and muscle spasm

The nurse assesses an elderly client with a diagnosis of dehydration and recognizes which finding as an early sign of dehydration?

Change in mental status

A client with Type I Diabetes complains of hunger, thirst, tiredness, and frequent urination. Based on these findings, the nurse should take what action?

Determine the client's blood glucose level.

An 85-year-old client is alert and able to participate in care. The nurse understands that, according to Erikson, a person's adjustment to the period of senescence will depend largely on adjustment to which developmental stage?

Generativity versus stagnation

A nurse is teaching Unlicensed Assistive Personnel (UAP) about ways to prevent the spread of infection. It would be appropriate for the nurse to emphasize that the cycle of the infectious process must be broken, which is accomplished primarily through:

Handwashing before and after providing client care.

To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what type of dietary plan does the nurse expect?

High in fluids

The nurse creates a plan of care for a client with a risk of infection. Which is the most desirable expected outcome for the client?

The client will be free of signs and symptoms of infection by discharge.

During history taking, a client reports experiencing black, tarry stools. The nurse recognizes that this may be an indication of:

Upper gastrointestinal bleeding.