Fundi Test week 12
A nurse is preparing to collect a urine sample for urinalysis using a reagent strip. The nurse should identify that the reagent strip can detect substances that are consistent with which of the following conditions? Diabetes Colon cancer Pancreatitis Pregnancy
Diabetes
A nurse is assessing a client who is experiencing disenfranchised grief. Which of the following findings should the nurse expect? Social isolation Verbalization of acceptance of the loss Shares feelings of grief with others Hypersomnia
Social isolation
A nurse is evaluating a client's bladder training program. Which of the following statements by the client indicates the bladder training was successful? "I am having accidents daily." "I am voiding a small amount when I visit the bathroom." "I continue to visit the bathroom every hour." "I am experiencing less than one urinary accident per week."
"I am experiencing less than one urinary accident per week."
Which of the following information should the nurse include about self-care? Restrict daily water intake Get at least 5 hours of sleep every night Exercise 1x week Bring Healthy meals to work
Bring Healthy meals to work
A RN is preparing to give insulin to a pt w/ type 1 diabetes. Which of the following types of prevention is this? Quaternary Primary Secondary Tertiary
Tertiary
A nurse is teaching a client who has a new prescription for an antihypertensive medication. The nurse should identify that antihypertensive medications are used for which of the following types of prevention? Secondary prevention Tertiary prevention Primary prevention Quaternary prevention
Tertiary prevention
A nurse is assessing a client who has dehydration. Which of the following findings should the nurse expect? Dark Colored Urine Distended Neck Veins Moist Skin High Blood Pressure
Dark Colored Urine
A nurse is preparing to insert a nasogastric tube into a client for decompression. Which of the following actions should the nurse perform first? Measure the tube from the client's ear to the xiphoid. Insert the tube while the client takes sips of water. Connect the nasogastric tube to suction. Ensure the client is in a sitting position.
Ensure the client is in a sitting position.
A nurse is reviewing the medical record of a client who has persistent diarrhea. Which of the following findings should the nurse identify as risk factors? (select all that apply) History of irritable bowel syndrome A shortened urethra Cardiovascular disease Consumes large amounts of dairy in their diet Currently taking antibiotics for an infection
History of irritable bowel syndrome Consumes large amounts of dairy in their diet Currently taking antibiotics for an infection
A nurse enters a client's room and stands near the client to ask them if they need anything. The client continues to watch the television, which is at a loud volume. Which of the following actions should the nurse take? Leave the client's room to go check on other clients. Ask the client why they are ignoring the question. Repeat the question in a loud voice. Lower the volume on the television.
Lower the volume on the television.
A nurse is caring for a client who is actively dying and is discussing pain management with the client's caregiver. Which of the following information should the nurse include? Pain control begins with the use of opioids. The use of nonpharmacological interventions is contraindicated. The use of pain medications can prolong the client's death. A combination of approaches is suggested to manage pain symptoms.
A combination of approaches is suggested to manage pain symptoms.
Which is an example of a non-modifiable risk factor? Age Smoking Vegan diet Weight
Age
A hospice nurse is caring for a client who is hallucinating and talking to someone who is not there. Which of the following actions should the nurse take? Tell the client that there is no one there. Ensure client safety and prevent injury. Decrease verbal interactions with the client. Reorient the client to reality.
Ensure client safety and prevent injury.
A nurse is educating a client who has a paraplegia about urinary catheter use. Which of the following catheter types should the nurse include in the teaching to help facilitate urinary elimination for this client? Suprapubic catheter Indwelling catheter Condom catheter Intermittent catheter
Intermittent catheter
A nurse is caring for a client whose partner recently died. In which step of the nursing process should the nurse and client identify the goals for the client's care? Implementation Evaluation Planning Analysis
Planning
A nurse is teaching a client who has constipation. Which of the following statements should the nurse include? "Try to defecate at different times of the day." "Reduce your daily activity." "Increase your daily fluid intake." "Consume a low-fiber diet."
"Increase your daily fluid intake."
A nurse is helping a client calculate how many net carbohydrates they consumed in their last meal. The client's food had a total of 72g of carbohydrates and 9 g of fiber. How many net carbohydrates did the client consume? 81 63 8 72
63 Total Carbohydrates - (Fiber + Sugar Alcohols if applicable) = Net Carbohydrates. In this case, 72 g carbohydrates - 9 g fiber = 63 net carbohydrates.
A nurse is inserting an NG tube for a client. Which of the following actions should the nurse take? Wear sterile gloves to insert the NG tube. Determine the length of the NG tube to be inserted prior to the procedure. Ask the client to cough while inserting the NG tube. Place the client into a left lateral position before inserting the NG tube.
Determine the length of the NG tube to be inserted prior to the procedure.
A nurse is preparing to administer an influenza vaccine to a client. The client states that they understand being immunized will help protect them against the influenza virus. Which of the following concepts is the nurse demonstrating by administering the vaccine? Health promotion Disease prevention Health outcomes Wellness
Disease prevention
A nurse is caring for a client who is actively dying. Which of the following actions should the nurse take for alterations in breathing pattern? Withhold opioids because they can hasten the client's death. Report changes in the respiratory pattern to the health care provider as they occur. Educate the family about the expected respiratory changes. Inform the family that oxygen therapy has no benefit.
Educate the family about the expected respiratory changes.
A nurse is teaching a client about the benefits of a healthy diet and regular exercise to achieve weight loss. Which of the following topics is the nurse teaching to the client? Health promotion Disease prevention Nonmodifiable risk factors Tertiary prevention
Health promotion
A nurse is caring for a client who has constipation. Which of the following diets should the nurse encourage the client to follow? Low fat High protein High fiber Low carbohydrate
High fiber
A nurse is reviewing hospice care services with a group of newly hired nurses. Which of the following information should the nurse include? Hospice services are terminated with the death of the client. Hospice services are limited to serving the client. Hospice care is an interdisciplinary team effort. Hospice care volunteer services are limited to direct client care.
Hospice care is an interdisciplinary team effort.
A nurse is caring for a client who has constipation and requires an enema. Which of the following actions should the nurse take when administering the enema solution? Instruct the client to lie on their right side with their left leg pulled up to their chest. Instruct the client to lie on their left side with their right leg pulled up to their chest. Instruct the client to lie on their left side with both legs pulled up to their chest. Instruct the client to lie on their right side with both legs pulled up to their chest.
Instruct the client to lie on their left side with their right leg pulled up to their chest.
A home health nurse is visiting a client who lives in an older home and is concerned about their child's exposure to lead pain in the house. The nurse should identify that which of the following is potential health risk from exposure to lead paint? Strabismus Dental caries Accelerated growth and development Learning disabilities
Learning disabilities
A nurse is caring for a client who is actively dying and notes the client's feet are purple and marbled. Which of the following findings should the nurse expect? The client's feet are warm to the touch. The client feels pain in the affected extremity. The client has a fever. Mottling is visible on the client's legs.
Mottling is visible on the client's legs.
A nurse is discussing the benefits of palliative care with a newly licensed nurse. Which of the following information should the nurse include? Palliative care is offered to clients whose cancer has been in remission for 5 years. Palliative care will increase the client's time spent in the health care facility. Palliative care reduces client satisfaction. Palliative care improves the client's quality of life.
Palliative care improves the client's quality of life.
A nurse is caring for a client who has a new prescription for dialysis three times a week. the client avoids eye contact while talking to the nurse and explains that they work two jobs to support their partner and two children. The client also states, "I don't know how I am going to have time for dialysis." Which of the following factors are influencing the client's communication? (Select all that apply) Psychosocial factors Cognitive factors Situational factors Environmental factors Physiological factors
Psychosocial factors Situational factors
A nurse is planning to reconcile medications for a client who speaks a different language than the nurse. Which of the following actions should the nurse take? Ask a staff member who speaks the same language as the client to interpret. Ask a family member of the client to interpret the information. Search the internet for an electronic application to use for translating. Request assistance from the facility's interpreter.
Request assistance from the facility's interpreter.
A nurse is providing discharge instructions to a client during a follow-up telephone call. Based on the Shannon-Weaver communication model, which of the following components of the model is the nurse demonstrating? Receiver Sender Channel Decoder
Sender
A nurse is teaching a group of guardians about primary prevention techniques. Which of the following topics should the nurse include as an example of primary prevention? Emphasizing the importance of well-child visits for the child Encouraging children who have asthma to participate in extracurricular activities Taking measures to decrease the risk of childhood injuries within the home Promoting a healthy lifestyle for children who are overweight
Taking measures to decrease the risk of childhood injuries within the home
A nurse is teaching a client about modifiable risk factors to their health. Which of the following should the nurse include as an example of a modifiable risk factor? Tobacco use Age Family history Race
Tobacco use
A nurse is planning care for a client who has an order for urinalysis. Which of the following tests should the nurse anticipate being ordered if the presence of white blood cells is detected on urinalysis? Urine culture Bladder scan 24-hour urine Stool culture
Urine culture
A nurse in the PACU is determining if a client has pain. The client is drowsy and opens their eyes to verbal stimuli but is unable to communicate their pain level. Which of the following actions should the nurse take? Administer an antagonist to reverse the effects of the anesthesia. Use an alternative method for determining the client's pain level. Administer a pain medication as prescribed for severe pain. Wait until the client is awake, alert, and able to vocalize their pain level.
Use an alternative method for determining the client's pain level.
A nurse is caring for a client who reports an improved diet, exercising 30 min a day for 5 days a week, and an overall sense of improved health. The nurse should identify that the client is describing a positive state of health known as which of the following? Health promotion Disease prevention Health outcomes Wellness
Wellness
A nurse is providing information to a client about what may happen if their urinary tract infection (UTI) is not treated. Which of the following statements by the client indicates an understanding of the information? "I can develop a kidney infection called pyelonephritis." "I might have urinary retention." "I might become incontinent." "I can develop functional incontinence."
"I can develop a kidney infection called pyelonephritis."
Urinary leakage due to nerve damage following a spinal cord injury, is which type of urinary incontinence? Urge Stress Reflex Overflow
Reflex
A nurse is teaching a client who is newly diagnosed with diabetes mellitus. The client tells the nurse, "Thank you. I never really knew what caused diabetes." Using the Schramm model of communication, the nurse should recognize the client's statements as an example of which of following components of the model? Sender Channel Feedback Receiver
Feedback
A nurse is teaching a newly licensed nurse about urinary retention. Which of the following clients should the nurse include as having an increased risk for this condition? A client who has an enlarged uterus A client who experiences frequent urinary tract infections A client who has an enlarged prostate A client who has chronic hypertension
A client who has an enlarged prostate
A nurse is caring for a client who has dysphagia (swallowing difficulties). Which of the following actions should the nurse take? Alternate the client's liquids and solids during meals. Turn on the client's television during meals. Instruct the client to tilt their head back while swallowing. Elevate the client's head of the bed to 45° during meals.
Alternate the client's liquids and solids during meals.
A nurse is caring for a client who was recently diagnosed with chronic kidney disease. The client asks the nurse, "Why me? This is not fair." The nurse should identify the client's statement as an expression of which of the following stages of grief? Denial Depression Bargaining Anger
Anger
A nurse is caring for a client who has renal disease and must limit potassium intake. Which of the following foods should the nurse instruct the client to avoid because they are high in potassium? (select all that apply) Apples Bananas Dried beans Spinach Tomatoes
Bananas Dried beans Spinach Tomatoes
A nurse is caring for a client whose spouse recently died. The client is from a different culture than the nurse. Which of the following information should the nurse consider when caring for the client? (select all that apply) Rituals used to cope with loss are universal across every culture. Cultural-based rituals can assist clients in handling the death of a loved one. Culture may determine how a client expresses their grief. Cultural practices do not dictate the expected length of mourning. Rituals regarding death direct what procedures are performed on the body after death.
Cultural-based rituals can assist clients in handling the death of a loved one. Culture may determine how a client expresses their grief. Rituals regarding death direct what procedures are performed on the body after death.
A nurse is preparing to assist with feeding a client who is at risk for aspiration. Which of the following actions should the nurse take? Position the client upright at a 45° angle. Turn on the television per the client's request. Avoid allowing the client to drink until meal is finished. Cut the client's food into small bites
Cut the client's food into small bites
A nurse is teaching a client about diagnostic urinary testing. Which of the following should the nurse include in the teaching about cystometric testing? Cystometric testing measures bladder capacity, pressure, and final capacity when the urge to urinate begins. Cystometric testing measures urine speed and volume. Cystometric testing measures bladder pressure when urinary leakage occurs. Cystometric testing measures electrical activity of the muscles and nerves of the bladder and sphincters
Cystometric testing measures bladder capacity, pressure, and final capacity when the urge to urinate begins.
A nurse is planning care for a client who is terminally ill and speaks a different language then the nurse. Which of the following actions should the nurse take? Use a family member as a translator. Allow an assistive personnel (AP) to translate for the client. Use the health care facility's interpreter services. Download a smartphone application from the internet
Use the health care facility's interpreter services.
A nurse is planning to teach new assistive personnel how to use a beside glucose monitor to check a client's blood glucose level. The nurse will include a 30-min-face-to-face lecture and a written copy of the step-by-step procedure. Which of the following modes of communication is the nurse using in the teaching plan? (select all that apply) Verbal Written Electronic Nonverbal Assertive
Verbal Written Nonverbal
A nurse is discussing the Dual Process Model of Grief with a newly licensed nurse. Which of the following statements should should the nurse make? "A client's grief will oscillate between loss-oriented grief and restoration-oriented grief." "During restoration-oriented grief, a client experiences intense feelings of guilt and sadness about the loved one's death." "A client is coping with secondary losses such as loss of income or housing during loss-oriented grief." "During loss-oriented grief, a client focuses on rebuilding their future without their loved one."
"A client's grief will oscillate between loss-oriented grief and restoration-oriented grief."
A nurse is caring for a client who states, "I feel like I don't have to eat a varied diet when I take my multivitamin." Which of the following responses should the nurse make? "If taken four or more days a week, a multivitamin provides all the nutrients you need." "As long as you take a multivitamin daily, you do not need to eat a varied diet each day." "A multivitamin should not be used in place of a nutritious diet." "As long as the multivitamin isn't generic, it can replace unhealthy dietary choices."
"A multivitamin should not be used in place of a nutritious diet."
A nurse is caring for a client who states, "I only eat a high in protein and carbohydrates." Which of the following responses should the nurse make? "Make sure to get enough servings of red meat in your diet daily." "Your diet is varied but should also be high in calorie intake." "A varied diet should be high in protein and carbohydrate consumption." "A nutritious diet should include carbohydrates, protein, fiber, and healthy fats."
"A nutritious diet should include carbohydrates, protein, fiber, and healthy fats."
A nurse is caring for a client who states, "I have been getting a lot of cavities lately, but I don't know what is causing them." Which of the following responses should the nurse make? "A lack of protein can cause a problem with cavities." "Cavities can be caused by a diet low in vitamin C." "Increasing your consumption of leafy green vegetables and tomatoes can help with this." "Drinking sugary beverages can make you prone to cavities."
"Drinking sugary beverages can make you prone to cavities."
A nurse is caring for a female client who has a prescription for a clean catch urine specimen. Which of the following statements by the client demonstrates an understanding of how to provide a urine specimen? "I need to wipe from front to back with a sanitary wipe." "I should place the urine sample cup in the refrigerator." "I will begin the urination process in the specimen cup." "I will urinate in the urine tray for the nurse to collect."
"I need to wipe from front to back with a sanitary wipe."
A nurse is teaching a client about foods that can irritate the bladder. Which of the following statements by the client indicates an understanding of the teaching? "I will still be able to drink chocolate milk." "I should avoid fruits that are acidic." "I will need to switch from regular soda to diet soda." "I can still use jalapeno peppers when cooking."
"I should avoid fruits that are acidic."
A nurse is teaching a client about the International Self-Care Foundation's seven pillars of self-care. Which of the following client statements indicates an understanding of the teaching? "I will perform moderate exercise several times each week." "I will wash my hands for 10 seconds before I eat." "I will increase my dietary intake of simple sugars." "I will limit my sun exposure to 1 hour in the middle of the day."
"I will perform moderate exercise several times each week."
A nurse in a provider's office is caring for a client who has hypertension during a follow-up appointment and is focusing on the client's ability to make healthy behavior changes. Which of the following statements by the nurse is an example of the use of affirmations? "I'm glad you decided to continue your fitness routine." "You could achieve better results if you applied yourself more." "You are adjusting very well for your age." "Reducing your caffeine intake is good, but you really need to stop completely."
"I'm glad you decided to continue your fitness routine."
A nurse is discussing macronutrients with a client. Which of the following statements should the nurse make? "Macronutrients include vitamins and minerals, which your body needs a large amount of." "Macronutrients include carbohydrates, proteins, and fats, which make up the majority of a person's diet." "Macronutrients include carbohydrates and fats, which your body needs very little of." "While essential, macronutrients should be limited to weekly consumption."
"Macronutrients include carbohydrates, proteins, and fats, which make up the majority of a person's diet."
A nurse is educating a client about a new temporary ileostomy. Which of the following statements by the client indicates an understanding of the teaching? "My ileostomy has an internal reservoir that collects waste." "My ileostomy is allowing my colon time to heal from the surgery." "My ileostomy must be accessed with a catheter to drain the waste." "My ileostomy is designed to be a permanent solution."
"My ileostomy is allowing my colon time to heal from the surgery."
A nurse is preparing to provide education to a group of newly licensed nurses about methods to enhance communication with clients. Which of the following statements should the nurse include? (select all that apply) "Interrupt the client occasionally during the conversation." "Respect the client during the conversation." "Use complex terms when explaining with the client." "Allow time for reflection during the conversation with the client." "Show empathy during the conversation with the client."
"Respect the client during the conversation." "Allow time for reflection during the conversation with the client." "Show empathy during the conversation with the client."
A nurse is caring for a client who is prescribed a low glycemic index diet. The client states, "I don't understand what this means." Which of the following responses should the nurse make? (Select all that apply) "The glycemic index of a food relates to its ability to increase the blood glucose level." "You should eat foods such as whole grains, fruits, and vegetables." "Consuming white bread will increase your blood glucose level slowly." "Try to limit or avoid potatoes due to their high glycemic index." "Foods with a high glycemic index will cause your blood glucose to increase rapidly."
"The glycemic index of a food relates to its ability to increase the blood glucose level." "You should eat foods such as whole grains, fruits, and vegetables." "Try to limit or avoid potatoes due to their high glycemic index." "Foods with a high glycemic index will cause your blood glucose to increase rapidly."
A charge nurse is discussing Worden's Four Task of Mourning with a newly licensed nurse. Which of the following statements should the charge nurse include? "Accepting the reality of the loss is the third task." "The pain of grief is experienced during the second task." "The client rearranges their life to live without their loved one during the fourth task." "During the third task, a client focuses on remaining connected to their loved one through positive memories."
"The pain of grief is experienced during the second task."
A nurse is using the NURSE mnemonic while speaking with a client who is experiencing grief. Which of the following responses by the nurse demonstrates the concept represented by the "U" in the NURSE mnemonic? "What is the most challenging aspect for you at this time?" "I am going to be here for you all night." "It sounds like you may be feeling overwhelmed." "There is a lot going on right now, how can I be of help to you?"
"There is a lot going on right now, how can I be of help to you?"
A nurse is providing postoperative instructions for a client who had kidney stone removal and placement of a nephrostomy tube. Which of the following statements by the client indicates an understanding of the instructions? "This tube will keep my ureters open in case of another stone." "This tube will remain permanently because I can't empty my bladder." "This tube goes directly into my bladder." "This tube is only temporary."
"This tube is only temporary."
A nurse is caring for a client who has a new prescription for parenteral nutrition. The client states, "I am scared that I will be on this therapy for the rest of my life." Which of the following responses should the nurse make? "There is a good chance you will have to be on this therapy for the rest of your life." "Parenteral nutrition is very common and should not interfere with your daily activities." "This type of nutrition can be lifelong, but it can also be temporary depending on how your nutritional needs change." "I am sure you will need parenteral nutrition temporarily."
"This type of nutrition can be lifelong, but it can also be temporary depending on how your nutritional needs change."
A nurse is caring for a client who is nearing the end of life. Which of the following responses by the nurse supports the client's dignity? (select all that apply) "What would you like to know about your medications?" "I expect you will feel much better in a few days." "What can I do to help you feel more independent?" "I think you should allow your family to make your health care decisions." "You must be getting tired of lying in bed."
"What would you like to know about your medications?" "What can I do to help you feel more independent?"
A nurse is teaching a client about hospice care. Which of the following information should the nurse include? (Select all that apply) "You must have a terminal illness." "You are eligible for hospice care if you are expected to live for 12 months." "You can continue treatment to cure your illness." "You accept palliative care for comfort." "The health care provider must officially state that you are terminally ill."
"You must have a terminal illness." "You accept palliative care for comfort." "The health care provider must officially state that you are terminally ill."
A nurse is conducting a preoperative assessment of a client. Which of the following statements is an example of the nurse using motivational interviewing? "You said that you're sad. What is making you feel sad?" "If you want to lose weight, why do you keep eating fast food?" "Have you always struggled with depression?" "Do you have any health problems?"
"You said that you're sad. What is making you feel sad?"
A nurse is caring for a client who has a high phosphorus level. Which of the following instructions regarding food should the nurse provide? "You should eat white bread." "You can drink 2 cups of milk per day." "You should limit broccoli to 3 cups per week." "You can have four servings of oatmeal per week."
"You should eat white bread."
A nurse is caring for a client whose provider prescribed a heart-healthy diet. Which of the following information should the nurse include for the client regarding heart-healthy diets? (Select all that apply) "You should limit saturated fats in your diet." "You should increase sodium intake to your taste." "Eat foods with whole grains in your new diet." "It's important to eat larger portions of fruits and vegetables." "Limiting high-calorie food intake will promote adherence to your new diet." "Continue to avoid skim milk and lean meats."
"You should limit saturated fats in your diet." "Eat foods with whole grains in your new diet." "It's important to eat larger portions of fruits and vegetables." "Limiting high-calorie food intake will promote adherence to your new diet."
A nurse is caring for a client who has a new prescription for a clear liquid diet. The client asks the nurse, "How long will I have to be on this type of diet?" Which of the following responses should the nurse make? "You will be on this diet as long as the provider feels you need to be." "You might be on this diet for a week or two." "You should not be on this diet for more than a few days." "You should speak with the provider about your concern."
"You should not be on this diet for more than a few days."
A palliative care nurse is preparing an in-service for newly hired staff members about common grief reactions. Which of the following information should the nurse include? ( Select all that apply) A client who is grieving often experiences a wide range of emotions. The anniversary date of a loss should not trigger feelings of sadness after a client has fully accepted the loss. A client may feel a sense of relief if the death of a loved one was expected. A client may experience difficulty concentrating and hallucinations as a psychological response to loss. Behavioral responses to grief can include the refusal to eat or participate in social activities.
A client who is grieving often experiences a wide range of emotions. A client may feel a sense of relief if the death of a loved one was expected. A client may experience difficulty concentrating and hallucinations as a psychological response to loss. Behavioral responses to grief can include the refusal to eat or participate in social activities.
A nurse is teaching a newly licensed nurse about health literacy. Which of the following information should the nurse include? The client's signature on the discharge instructions ensures they understood the instructions. Clients who can read and write demonstrate health literacy. A client's comprehension of education can be affected by low health literacy. Health literacy affects only a small portion of clients who are cared for within the health care system.
A client's comprehension of education can be affected by low health literacy.
A nurse is discussing types of grief with a group of clients who have a serious illness. Which of the following information should the nurse include? Anticipatory grief occurs prior to the actual loss of someone or something. Normal grief lasts no more than 4 months after a loss has occurred. Disenfranchised grief occurs when a client is unable to accept the death of a loved one. Prolonged grief is defined as the loss of a relationship that is considered socially unacceptable.
Anticipatory grief occurs prior to the actual loss of someone or something.
A nurse is caring for a client who has a terminal illness and reports felling isolated from family and friends. Which of the following actions should the nurse take? Limit visitors to one to two people. Assist in scheduling friends and family to visit. Discourage face-to-face visits for the client. Instruct the client to limit their use of online support groups.
Assist in scheduling friends and family to visit.
A charge nurse is reviewing Kubler-Ross's five stages of grief with a newly licensed nurse. Which of the following statements should the nurse make? (Select all that apply.) The five stages occur in a specific order for every client. Clients might not go through all five stages of grief. Clients can return to a stage of grief after moving into one of the other stages. Client who are grieving might attempt to bargain with a higher power. The stages of grief are only experienced by clients who have a terminal diagnosis.
Clients might not go through all five stages of grief. Clients can return to a stage of grief after moving into one of the other stages. Client who are grieving might attempt to bargain with a higher power.
A nurse is planning to use a female external urinary catheter. Which action should the nurse plan to take? Apply a barrier cream to the client's perineal skin. Replace the external urinary catheter once each day. Insert the catheter into the client's urethra. Connect the catheter to continuous wall suct
Connect the catheter to continuous wall suct
A nurse is caring for a client who has a history of irritable bowel syndrome and reports that their last bowel movement way 5 days ago. The nurse should identify this as which of the following types of altered elimination pattern? Encopresis Diarrhea Fecal incontinence Constipation
Constipation
A nurse is caring for a client who reports occasionally having dark, tea-colored urine at home. The nurse identifies that which of the following activities can contribute to this finding? Attending a yoga class Consuming alcohol Drinking 2,000 mL of fluid in a day Consuming fish for dinner
Consuming alcohol
A hospice nurse is caring for a client who states that they want to have their last rites before they die. The nurse recognizes that which of the following factors is influencing the client's request? Cultural factor Developmental factor Environmental factor Physiological factor
Cultural factor
A nurse is reviewing Kubler-Ross's five stages of grief. The nurse should identify that Kubler-Ross placed the stages in which original order? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps) Anger Denial Bargaining Acceptance Depression
Denial Anger Bargaining Depression Acceptance
A nurse is caring for a client who has a terminal illness and states that they want to experience a "good death." Which of the following actions should the nurse take? Determine the client's definition of a "good death." Inform the client that culture is irrelevant to an individual's perception of a "good death." Inform the client that a "good death" is not possible. Communicate with the client that caregivers are prevented from providing a "good death" for the client.
Determine the client's definition of a "good death."
A nurse is preparing for an initial visit with a client who is experiencing grief. Which of the following tasks should the nurse plan to complete first? Provide information to the client about the stages of grief. Encourage the client to share thoughts about their loss. Develop a relationship with the client. Ask the client if they are experiencing physical manifestations of grief.
Develop a relationship with the client.
A nurse is providing postmortem care for a client. Which of the following actions should the nurse take? (Select all that apply) Document where the body is being moved. Include the name of anyone notified in the medical record. Document the date and time of death. Ensure the client's belongings are accounted for. Place an identification tag on a minimum of one area of the client's body.
Document where the body is being moved. Include the name of anyone notified in the medical record. Document the date and time of death. Ensure the client's belongings are accounted for.
A nurse is caring for a client with suspected dehydration. For which of the following findings should the nurse monitor this client? Oral temperature of 36.4°C (97.5°F) Light yellow urine Dry mucous membranes Diaphoresis
Dry mucous membranes
A nurse is planning teaching for a client about wound care. Which of the following actions should the nurse take? Use medical terminology during teaching. Sit across from the client at a table in the cafeteria during teaching. Ensure the client is wearing their glasses during teaching. Use the communication technique of probing during teaching.
Ensure the client is wearing their glasses during teaching.
A nurse is planning a presentation about skin care for a group of older adult clients at a senior center. Which of the following actions should the nurse take to enhance client learning? Ensure the room is well lit. Have soft music playing in the background. Hand out samples of products during the teaching. Speak quickly during the teaching.
Ensure the room is well lit.
A nurse is speaking to a client who smokes tobacco and has a child living in the home. The nurse should identify that the child's exposure to second-hand smoke is an example of which of the following types of risk factors? Cultural Societal Heredity Environmental
Environmental
A nurse is instructing a client regarding heart-healthy activities. This action represents which of the following phases of the nurse-client relationship? Identification Orientation Exploitation Resolution
Exploitation
Modifiable risk facts are things that patients have no control over. True False
False
A nurse is planning care for a client who reports blood in their stool. Which of the following tests should the nurse anticipate the provider ordering? Fecal occult blood test Stool culture Flexible sigmoidoscopy Endoscopic retrograde cholangiopancreatography (ERCP)
Fecal occult blood test
A nurse is caring for an adult client who is mourning the death of a sibling. Which of the following information should the nurse consider when caring for the client? Older adult clients tend to experience fewer losses of loved ones. Grief differs for adults due to their full understanding of death and memories of the deceased. Adults usually do not report physical manifestations associated with experiencing grief. Experiencing bereavement is not as common in adults when compared to clients in other age groups.
Grief differs for adults due to their full understanding of death and memories of the deceased.
A nurse is planning care for a client who has a new colostomy. Which of the following complications should the nurse plan to monitor for? Hernia Gastroesophageal reflux disease Crohn's disease Ulcerative colitis
Hernia
A nurse is caring for a client for who recently lost their job. Which of the following actions should the nurse take during the assessment step of the nursing process? (Select all that apply) Identify whether the client is experiencing feelings of grief. Avoid discussing the client's recent job to prevent upsetting the client. Check the client for physical manifestations of grief. Ask the client about their support system. Provide education about the grief process to the client.
Identify whether the client is experiencing feelings of grief. Check the client for physical manifestations of grief. Ask the client about their support system
A nurse is caring for a client who reports having daily constipation. Which of the following information should the nurse provide to the client regarding fiber intake? (Select all that apply) Increasing daily fiber intake can help alleviate the issue of constipation. Eating more whole grains can promote regular bowel movements. Consume 10 g of fiber per day. Foods such as white rice increase fiber intake. Decreasing daily fiber intake can help alleviate digestive discomfort.
Increasing daily fiber intake can help alleviate the issue of constipation. Eating more whole grains can promote regular bowel movements.
A RN is teaching about the function of the large intestine. Which of the following information should the nurse include? It secretes enzymes to digest food. It absorbs liquid to form stool. It prevents the reflux of food into the esophagus. It produces vitamin D.
It absorbs liquid to form stool.
A nurse is discussing culturally competent care with another nurse. Which of the following information should the nurse include? It is culturally insensitive to talk about impending death in some cultures. Most cultures agree with the use of opioids to treat pain. A client's cultural information should be obtained from a coworker. Culture is irrelevant when a client is making a health care decision.
It is culturally insensitive to talk about impending death in some cultures.
A nurse is caring for a client who is receiving tube feedings via PEG. Which of the following actions should the nurse implement in order to help prevent the client from aspirating? Keep the client's head elevated to at least 30° for a minimum of 1 hr after a feeding. Verify the initial tube placement with an x-ray after the first feeding. Check the client's tube feeding tolerance every 12 hr. Check the pH of the gastric contents each day.
Keep the client's head elevated to at least 30° for a minimum of 1 hr after a feeding.
A nurse at a hospital is interviewing a newly admitted client. The client tells the nurse they would like to adhere to their cultural beliefs during their hospitalization. Which of the following actions should the nurse take to provide the client with culturally competent care? (select all that apply) Listen to the client's request with respect and compassion. Let the client know that their cultural beliefs will be checked on after the assigned nursing break. Reassure the client that they can practice their cultural beliefs if safe to self and others. Explain to the client that this is not possible in a public space. Provide resources to meet the client's cultural needs.
Listen to the client's request with respect and compassion. Reassure the client that they can practice their cultural beliefs if safe to self and others. Provide resources to meet the client's cultural needs.
A nurse is caring for an older adult client who is experiencing urinary leakage. Which of the following is an expected age-related change that can contribute to this occurrence? Reduced blood supply Loss of kidney tissue Loss of nephrons Loss of bladder tone
Loss of bladder tone
A nurse is assessing a client who is getting divorced and reports feelings of loss associated with no longer being in the role of a spouse. The nurse should identify the the loss of a previously held role is which of the following types of losses? Loss of autonomy Loss of dreams and expectations Loss of safety Loss of identity
Loss of identity
A nurse is caring for a client who is actively dying. The client's caregivers state they are interested in donating the client's organs. Which of the following actions should the nurse take? Discuss the process of organ donation with the caregiver. Make a referral to an organ procurement organization. Inform the caregiver that only the client can give authorization for organ donation. Notify the health care provider since they are responsible for discussing organ donation with the family member.
Make a referral to an organ procurement organization.
A nurse is preparing to measure a nasogastric tube for insertion. The nurse recalls that the client's xyphoid process should be used as the last place of measurement. Which of the following landmarks should the nurse measure before the xyphoid process? Measure from the bottom of the ear. Measure from the tip of the chin. Measure from the bottom of the jaw line. Measure from the tip of the nose to the earlobe.
Measure from the tip of the nose to the earlobe.
A nurse is assessing a client who came to the emergency department reporting chest pain. The client tells the nurse they have hearing loss and forgot to bring their hearing aid with them. Which of the following actions should the nurse take to improve communication with the client (select all that apply) Move the client to a quiet area or private room. Speak at a slower pace. Delay the assessment until the client's family member brings the hearing aid. Have a sign language interpreter translate the communication with the client. Stand next to the client when talking. Avoid using medical terminology
Move the client to a quiet area or private room. Speak at a slower pace. Avoid using medical terminology
A nurse is reviewing a client's list of medications and supplements. Which of the following medication classifications increases the risk of constipation? Magnesium-containing antacids Antibiotics Narcotic pain medications Beta blockers
Narcotic pain medications
A nurse is assessing a client who is experiencing digestive issues. Which of the following findings should the nurse expect? (select all that apply) Nausea Abdominal pain Diarrhea Reports of bloating Reports of excessive salivation
Nausea Abdominal pain Diarrhea Reports of bloating
A nurse is obtaining a health history from a client who is newly admitted. The nurse notices that the client does not make eye contact and their arms are folded across their chest. The nurse should recognize that the client is using which of the following forms of communication? Auditory Nonverbal Emotional Energetic
Nonverbal
A nurse is discussing hospice care services with the caregiver of a client who is terminally ill. Which of the following information should the nurse include? Nursing support will be provided in meeting the client's daily needs, including the administration of medications. The caregiver can request their terminally ill loved one be admitted to a professional care facility for a maximum of 2 days. Nurses are not allowed to become a confidant to the caregiver. Nurses will have limited contact with the client and caregiver.
Nursing support will be provided in meeting the client's daily needs, including the administration of medications.
A nurse is teaching a client about nutritional supplements. Which supplement is used to promote heart health? Lutein Vitamin D Omega-3 fatty acids Folic Acid
Omega-3 Fatty Acids
A nurse is assessing a client who has an indwelling urinary catheter and determines that the catheter is in place and functioning properly. The nurse should expect which of the following findings? Dark yellow, cloudy urine Pale yellow, clear urine Urine with a strong odor Urine with a slight red tint
Pale yellow, clear urine
A nurse is discussing palliative care with a client who has colon cancer. Which of the following information should the nurse include? Palliative care is limited to a specific time frame. Palliative care uses a holistic approach. Palliative care is provided after the client has stopped curative treatment methods. Palliative care is offered to clients who have non-life-threatening illnesses.
Palliative care uses a holistic approach.
A nurse is grieving following the death of a client who had a terminal illness and is having difficulty sleeping and concentrating. Which of the following actions should the nurse take? Avoid talking with more experienced nurses about coping with the death of a client. Refrain from attending the client's funeral. Participate in an exercise program. Distance themselves from the client's family.
Participate in an exercise program.
A nurse calls the unit to say that they will be late for their shift. The charge nurse responds, " Don't worry, take your time and be safe" After hanging up the phone, the charge nurse then says to staff at the nurses' station, "I'm tired of that nurse always being late. I wish someone would do something about their tardiness." Which of the following communication styles is the charge nurse demonstrating? Assertive Aggressive Passive-aggressive Passive
Passive-aggressive
A nurse is caring for a client who has a colostomy and does not wear a colostomy pouch. Which of the following actions should the nurse anticipate performing on this client to maintain expected bowel function? Administer an enema. Administer a laxative. Perform colostomy irrigation. Insert a rectal tube.
Perform colostomy irrigation.
A nurse is caring for a nondiabetic client who has a new prescription for a fasting blood glucose check. The nurse checks the client's blood glucose and it is 67 mg/dL. Which of the following actions should the nurse take next? Document the client's blood glucose level. Report the client's blood glucose level to the provider. Provide the client with a 15-g carbohydrate snack. Recheck the blood sugar in 15 min.
Provide the client with a 15-g carbohydrate snack.
A nurse learns that a coworker has died unexpectedly. Which of the following actions should the nurse take? Keep personal feelings of grief to themselves. Recognize their feelings of grief. Attempt to ignore physical manifestations of grief. Avoid family and friends when feeling deep sadness.
Recognize their feelings of grief.
A charge nurse is preparing an in-service for staff members about spiritual influences on grief. Which of the following information should the nurse include? Many religions reject the idea of reincarnation after death. Religion can provide comfort during the grieving process. Sensitivity to religious beliefs is not a priority in the delivery of client-centered care. Spirituality and religious beliefs can hinder post-bereavement outcomes.
Religion can provide comfort during the grieving process.
A nurse manager is planning to introduce a new scheduling policy to the unit staff. Which of the following methods of communication should the nurse manager use? Send an email to staff via the facility's email system. Schedule a face-to-face unit staff meeting. Place a copy of the policy on a bulletin board in the hallway. Leave a voicemail on each staff member's phone.
Schedule a face-to-face unit staff meeting.
A nurse at a clinic is providing free blood pressure screenings for clients. Which of the following levels of health prevention is the nurse demonstrating? Tertiary prevention Secondary prevention Primary prevention Quaternary care
Secondary prevention
A nurse is caring for a client who has dementia. Which of the following communication strategies should the nurse implement to communicate with the client? Explain the daily schedule to the client in detail. Turn the overhead lights on in the client's room when speaking with them. Speak in a loud voice to the client. Speak to the client clearly and at a slow pace.
Speak to the client clearly and at a slow pace.
A nurse is discussing the concept of spirituality with a newly licensed nurse. Which of the following information should the nurse include? Spirituality can be easily defined. Spirituality is similar for all clients. Religion and spirituality are interchangeable. Spirituality focuses on the significance and purpose of life.
Spirituality focuses on the significance and purpose of life.
A nurse is caring for a client who is receiving antibiotic treatment for a urinary tract infection and is experiencing diarrhea. Which of the following should the nurse identify as a potential cause of the diarrhea? The antibiotic dose is not correct, and the provider should be alerted. The antibiotic interferes with the client's ability to absorb nutrients. The antibiotic eliminates the healthy gastrointestinal bacteria, allowing harmful bacteria to grow. The antibiotic decreases a client's immunity level, resulting in diarrhea.
The antibiotic eliminates the healthy gastrointestinal bacteria, allowing harmful bacteria to grow.
A nurse is assessing a school-age child whose friend recently died. Which of the following findings should the nurse expect? The child believes that their friend's death is temporary. The child clings to people. The child holds back their feelings. The child thinks they are to blame for their friend's death.
The child holds back their feelings.
A nurse is assessing a 16-year-old client whose parent recently died. Which of the following findings should the nurse expect? The client is still developing an understanding of death. The client feels that "everyone understands me." The client can easily express their emotions. The client displays high-risk behaviors.
The client displays high-risk behaviors.
A nurse is assessing a client's hair and notes that it is brittle. Which of the following should the nurse determine about the client's nutritional intake? he client is not getting enough vitamin A. The client has insufficient protein in their diet. The client needs more vitamin D from sun exposure. The client needs to eat five servings of fruits and vegetables daily.
The client has insufficient protein in their diet.
A nurse is caring for a client who routinely eats a regular diet and is scheduled to have surgery with sedation in the morning. The nurse receives a new NPO diet prescription for the client. Which of the following should the nurse identify as the rational for the provider's prescription? The client is at risk for aspiration due to the upcoming surgery. The client is at risk for dysphagia due to the upcoming surgery. The nutrients consumed as a part of the regular diet will interact with the sedation used in the procedure. The client reports having to drink a few sips of water before the procedure.
The client is at risk for aspiration due to the upcoming surgery.
A nurse is reviewing a client's medical record and notes that their BMI is 25.5. How should the nurse interpret this finding? The client is overweight. The client is underweight. The client's BMI is within normal range. The client is obese.
The client is overweight.
A nurse is caring for a client who has a prescription for a vitamin K injection. The nurse should identify that vitamin K is naturally produced in which of the following locations in the body? The small intestine The large intestine The esophagus The stomach
The large intestine
A nurse is discussing the Healthy People initiative with a newly licensed nurse. Which of the following information should nurse include? The program focuses on decreasing the occurrence of cancer in people. The program focuses upon issues related to global health. The program focuses on providing goals and data for improved public health. The program focuses on reducing the viruses acquired by people.
The program focuses on providing goals and data for improved public health.
A nurse is reviewing the primary function of the urinary tract with a group of newly licensed nurses. Which of the following information should the nurse include? The urinary tract regulates the production of red blood cells. The urinary tract produces hormones for blood pressure regulation. The urinary tract keeps bones strong. The urinary tract eliminates waste and excess fluid from the body.
The urinary tract eliminates waste and excess fluid from the body.
A nurse is caring for a client who is actively dying. The client's caregiver ask the nurse about the client's noisy respirations. Which of the following information should the nurse include?(select all that apply) They can be an indication of approaching death. Deep suctioning is effective in removing trapped secretions. Turning the client's head to the side can assist with drainage. Medications can be administered to help dry up the secretions. The client is unable to clear the secretions themselves.
They can be an indication of approaching death Turning the client's head to the side can assist with drainage Medications can be administered to help dry up the secretions The client is unable to clear the secretions themselves
A nurse is caring for a group of clients who are at risk for an alteration in urinary elimination. Which of the following groups should the nurse identify as being at an increased risk? (select all that apply) Uncircumcised infants School-age children Middle adults Older adults Young adults
Uncircumcised infants School-age children Older adults
A nurse is caring for a client who has a stone in the right ureter that is obstructing that flow of urine. Which of the following urinary diversions should the nurse anticipate the client will need? Urostomy Continent cutaneous reservoir Ureteral stent Neobladder
Ureteral stent
A nurse is assessing a client who has stress incontinence. Which of the following findings should the nurse expect with this client? Urine leakage prior to reaching the toilet Urine leakage following coughing Urine leakage as a result of nerve damage Urine leakage due to not reaching the toilet in time from a physical impairment
Urine leakage following coughing
Which of the following is a water soluble vitamin? Vitamin A Vitamin D Vitamin C Vitamin E
Vitamin C
A nurse is preparing to administer an enema to a client. Which of the following actions should the nurse plan to take? Lubricate the tubing with an oil-based lubricant. Warm the enema solution to room temperature. Use sterile technique. Place the client into a right lateral position.
Warm the enema solution to room temperature.
