N206 Exam 1

When assessing the client's pulse, the nurse should use which assessment technique

palpation

The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk?

predisposition to renal calculi

The mother of a toddler is deciding if she wants to allow her child to receive the recommended immunizations. The clinic nurse responds, "If you don't immunize your child you are jeopardizing the health of other children." What type of approach does this response indicate?

guilt inducement or approval/disapproval

A patient with iron deficiency has a common complication that results in an inflammation of the tongue. What is the term used for this condition?

glossitis

A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based upon improvements in his condition. This is an example of which type of planning?

ongoing planning

A nurse accidentally gives a double dose of blood pressure medication. After ensuring the safety of the client, the nurse would record the error in which documents?

Client's record and occurrence report

The nurse has asked the client to grasp his overbed trapeze and pull his torso up off the surface of the bed. What movement will the client perform with his arms?

Flexion

The nurse is discussing car safety with the mother of a 6-year-old child. The child's mother questions the need for the use of special car seats for her child. What information can be provided to her?

"At the age of 6 your child should be using a booster seat."

What guides professional practice?

CNA Standards of Nursing Practice

The unlicensed assistive personnel (UAP) has taken vital signs. The nurse is currently logged into the electronic health record, and the UAP needs to document the vital signs. How does the nurse answer the UAP's request to document?

"I will log out of the electronic health record and you can log in to document."

The nurse is currently completing the last of three consecutive night shifts. The unit will be short-staffed on day shift and the charge nurse wants the nurse to work this as an overtime shift. What is the nurse's most appropriate response?

"I will not work tomorrow because I would be a danger to my clients."

A nurse is assisting a client with his bed bath. The client states, "I can do it myself." Which is the nurse's best response?

"I will set up your bath for you. I will come back and help you with your bath."

The nurse is caring for a client admitted with acute pancreatitis. The client is nauseated and receiving IV fluids at 125 mL/hr, The client is NPO and has received Morphine sulfate 4 mg IV for pain with a decrease of epigastrc pain of a 4/10 on the pain scale. Because the facility charts by exception, which progress note represents this method?

4/10 pain on pain scale, epigastric pain; with reports of nausea

The nurse is teaching the client and the family safe methods to increase activity tolerance. Which teaching should the nurse include? Select all that apply.

-Allow adequate time for performing activities. -Remove objects that are safety hazards from the environment. -Develop hobbies or recreational interests. -Promote independence by contacting services such as Meals on Wheels.

Which nursing actions are recommended guidelines when performing oral care? Select all that apply.

-Ideally, brush teeth immediately after eating or drinking. -If desired, use an automatic toothbrush to remove debris and plaque from teeth. -If desired, use salt and sodium bicarbonate as cleaning agents for short-term use.

The nurse is developing cognitive outcomes for a client. Which outcome statements would be in the cognitive realm? (Select all that apply.)

-Within 1 week after teaching, the patient will list three benefits of quitting smoking. -By 6/8/15, the patient will describe a meal plan that is high in fiber. -After viewing the film, the patient will verbalize four benefits of daily exercise.

A nurse is using Gordon's functional health patterns as an organizing framework for client assessment. The client has significant problems related to breathing for which the nurse identifies several nursing diagnostic labels, including ineffective breathing pattern and impaired gas exchange. The nurse understands that these nursing diagnoses would be organized under which functional pattern?

Activity-exercise

The nurse recognizes that health problems that can be prevented by independent nursing interventions are called what?

Actual or potential nursing diagnoses

A nurse is caring for a female client with diarrhea. What instruction should the nurse give the client with regard to perineal hygiene?

Clean the perineal area from the front to back.

Which client situation most likely warrants a time-lapse nursing assessment?

An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit.

A client is receiving home care due to an unstable blood pressure. Which nursing intervention is a priority?

Assess the client's blood pressure.

A homeless client in the public health clinic has a strong body odor and is wearing clothes that are visibly soiled. What nursing diagnosis would be most appropriate for the nurse to identify?

Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor

Which action exemplifies the purpose of evaluation in the nursing process?

Continue, modify, or terminate patient care.

Nurses perform many independent nursing actions when caring for patients. Which action is considered an independent (nurse-initiated) action?

Helping to allay a patient's fears about surgery

A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do?

Individualize the plan to the client.

The nurse is preparing a client with a bowel obstruction for emergency surgery. Of the following interventions, which has the highest priority?

Inform the client what to expect after the surgery. If the surgery is an emergency, the highest priority is to meet the client's immediate needs. The nurse should inform the client about what to expect after surgery. Discussing discharge plans, instruction in wound care, and dietary restrictions are important, but not necessary before the surgery.

A nurse documents the diagnosis of: "Risk for Imbalanced Nutrition: More Than Body Requirements" for a client that is hospitalized. What is the major goal of interventions for a risk diagnosis?

Prevention of an actual problem

The nursing is caring for a client who requests to see a copy of his or her health care records. What action by the nurse is most appropriate?

Review the hospital's process for allowing clients to view their health care records.

Which statement is true of the nursing process?

Scientific problem solving can occur within the nursing process.

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure ulcer on his coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation?

The hospital must bear any costs incurred for treating the client's ulcer.

When caring for a client in the emergency room who has presented with symptoms of a (MI) myocardial infarction, the nurse orders laboratory tests and administers medication to the client before the physician has examined the client. In order for the nurse to be operating within the nurse's scope of practice, what conditions must be present?

The nurse is operating under standing orders for clients with MIs.

A nurse follows the universal patient compact principles for partnership when providing care for patients. Which nursing action does not reflect this philosophy?

The nurse makes health care decisions for a patient who is uncooperative.

During morning report, the night nurse tells the day nurse that the client refused to allow the technician to draw blood for laboratory testing. What step would be essential for the day nurse to complete before selecting a nursing diagnosis to address this issue?

The nurse should determine the reason for the client's refusal.

During a home health care visit, the nurse identifies a nursing diagnosis of Caregiver Role Strain for a parent who is caring for a child dependent on a ventilator. What subjective assessment data would support the nurse's diagnosis?

The parent states, "I cannot allow anyone else to help because they won't do it right."

A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on her activities of daily living (ADLs) during her period of recovery. When should discharge planning to address ADLs begin for this client?

Upon her admission to the hospital Discharge planning should begin when a client is admitted for treatment.

Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy?

focused assessment

A nurse is assessing a client with chronic back pain and asking specific questions to obtain a focus assessment. Which of the following are features of a focus assessment?

adds depth to existing information

The nurse is reviewing the plan of care for assigned clients. Which client has the highest risk for developing an infection?

an older adult client with a history of heart failure Many factors affect the risk for infection, including age, sex, race, and heredity. Neonates and older adults, especially those who have pre-existing illnesses, appear to be more vulnerable to infection. School-age children are exposed to potential infections, but immunizations protect the child. An adolescent with a fracture or middle-aged adult taking medication to control BP could develop an infection, but not the highest risk.

A nurse is caring for a post-operative client 1 day after a total abdominal hysterectomy. Which nursing intervention demonstrates caring?

assisting the client to sit up in a chair not: monitoring vital signs

The nurse is teaching a client and caregivers about ways that HIV can be transmitted. Which methods of infection transmission will the nurse include? (Select all that apply.)

blood secretions non intact skin mucous membranes insulin syringe used by the client

Which structures are primarily responsible for voluntary movement? Select all that apply

cerebellum, cerebral cortex, pyramidal tract

Which cultural group may interpret touch by another as an invasion of privacy?

chinese

The nurse is caring for a client with a draining abscess. Which precautions will the nurse begin?

contact

When recording or documenting outcome attainment in the chart, nurses are to be very clear with the descriptions used. Which term is appropriate?

demonstrated steps

What gives additional meaning to a nursing diagnosis?

descriptors

The purpose of obtaining a nursing history is to:

identify actual and potential nursing diagnoses

A client is brought to the emergency room in respiratory arrest and immediately intubated and placed on mechanical ventilation. What is the most appropriate nursing diagnosis for this client?

impaired spontaneous ventilation

The nurse is documenting a variance that has occurred during the shift. This report will be used for quality improvement to identify high-risk patterns and, potentially, to initiate in-service programs. This is an example of which type of report?

incident report

A nurse communicating with a client states, "I will be changing your dressing, but we have plenty of time to talk first." She is already wearing sterile gloves and a mask and is busy working with her back to the client. The nurse is conveying a (an)

incongruent relationship. What the nurse is communicating verbally and nonverbally are incongruent with each other. Even though the nurse is verbally saying that he or she has time to talk, the nurse's nonverbal actions demonstrate that he or she is ready to perform the procedure. In addition, the back turned to the client while speaking demonstrates closed communication.

When the nurse cleanses the client's leg during a bed bath, it will allow for:

increased circulation.

When caring for a client, the nurse identifies and analyzes data to identify nursing diagnoses and collaborative problems. Which action is a priority role of the nurse when caring for a client with collaborative problems?

reporting trends that suggest development of complications

An infection or the products of infection carried throughout the body by the blood is called:

septicemia

The nursing supervisor is evaluating how many clients each of the department nurses has been assigned for the shift. This type of evaluation would be considered:

structure

The type of intervention that the nurse performs when he or she observes the spouse of a postoperative client performing the client's dressing change is described as

supervisory

The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client?

the 24-month-old child who is unable to walk unassisted

The nurse is developing outcomes for the care plan of a client admitted with Parkinson's disease. The nurse will derive the outcomes for this client's care plan from:

the problem statement of the nursing diagnosis. Outcomes are derived from the problem statement of the nursing diagnosis. Remember that the nursing process is based upon independent nursing actions.

The nurse is working to increase functional ability with a client. Which assistive technique should be included in the plan of care?

trapeze bar

The nurse has completed teaching regarding pediculosis. Which client statement requires further nursing teaching?

"I will use conditioner so that the lice eggs will slide off my hair."

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response?

"Only authorized persons are allowed to access client records."

Which statement made by the nurse indicates data that would be documented as part of an objective assessment?

"The client's right leg is cold to the touch, from the knee to the foot."

A nurse is planning a class for hospital nurses on the use of nursing diagnoses in client care. When discussing possible arguments that have been made against the use of nursing diagnoses, what information will the nurse include? Select all that apply.

-Nursing diagnoses apply limits to nursing practice. -Nursing diagnoses discourage innovative thinking. -Nursing diagnoses focus on negative client factors. -Nursing diagnoses promote a paternalistic attitude from health care providers.

A nurse is providing care to an older adult client diagnosed with heart disease. The nurse uses the nursing process to provide individualized care using the actions listed below. Place the actions in the order that the nurse would most likely complete them using the nursing process.

-obtains the client's vital signs -identifies risk for fluid volume excess -develops a realistic goal for monitoring fluid balance -prepares an individualized strategy for addressing risk -obtains the client's weight daily. -determines that the client's fluid balance is stabilized

A nurse is caring for a client 4 hours following closed reduction and casting of a radial fracture. The client reports pain at 9 on a 1 to 10 scale, and capillary refill is greater than 3 seconds. The cast is bivalved and capillary refill is observed at 2 seconds. What is the best modification to the care plan by the nurse?

Perform hourly neurovascular assessment. not: give prescribed pain meds

Which health problem is most clearly suggestive of a history of inadequate dental care?

Periodontitis, or periodontal disease, is a marked inflammation of the gums that also involves degeneration of the dental periosteum (tissues) and bone; it is suggestive of deficits in dental and oral hygiene. Cheilosis is indicative of vitamin deficiency. Dry oral mucosa is not indicative of inadequate dental hygiene. Alopecia is hair loss.

A female client undergoing chemotherapy for breast cancer has lost all her hair. The client states, "I cannot stand to see myself without hair. I am disgusting." What would be the most appropriate nursing diagnosis for the nurse to use to address this client's problem?

Disturbed Body Image related to loss of hair

A 50-year-old male is admitted for removal of a cancerous tumor of his lung. He tells the RN he is worried about how the cancer and the treatment will affect his family. He explains his wife has never worked outside the home and he is concerned their financial situation will be compromised by his illness. Which of following would be the best nursing diagnosis for this patient?

Interrupted Family Processes

The nurse working at a local community hospital understands the importance of having a client database for continuous data collection. What does the nurse identify as the the primary reason for collecting data continuously?

It is because the client's health status can change quickly

The nurse adjusts a client's bed to a comfortable working height in order to turn a patient. What would be the nurse's next action?

Move the client to edge of the bed opposite the side that client will be turning.

The nurse is coordinating care for the client with continuous pulse oximetry who requires pharyngeal suctioning. Which staff member should the nurse avoid delegating the task of suctioning?

Nursing assistant who is a nursing student

The emergency room has a strict protocol regarding IM (intramuscular) injection technique. A nurse working in the emergency room has learned of a new technique to decrease pain with IM injections and would like to use it. What is the most appropriate way for the nurse to implement the technique?

Petition to change the protocol based on the new evidence.

A nurse has developed a plan of care for an adult client. What nursing function is important when using a nursing diagnosis to guide the care of this client?

Prioritize the nursing diagnoses.

What is the best example of person-centered care provided by a registered nurse?

Reassuring a client that is anxious about a procedure

The nurse on a medical surgical unit notices smoke from a client's room. Upon entering, the nurse notes that the curtain in the room is on fire. Which of the following should be the nurse's first action?

Remove the client from the room.

A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care?

Seek research about the disorder.

Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight?

Shift their weight back and forth, from back leg to front leg.

The nurse is caring for a client with rectal bleeding. The nurse will place the client into which position to facilitate rectal examination?

Sims (semi prone)

The nurse is caring for a 10-year-old client who is newly diagnosed with a seizure disorder. What variable would alter the nurse's plan for educating the client and parent?

The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years.

Which client outcome is a cognitive outcome? Select all that apply.

The client lists the side effects of digoxin (Lanoxin). The client describes how to perform progressive muscle relaxation. The client identifies signs and symptoms of hypoglycemia.

A client diagnosed with advanced lung cancer has a nursing diagnosis of Ineffective Coping. What assessment data would provide evidence to the nurse for this diagnosis?

The client states, "I am sure the doctors have misdiagnosed me."

An unconscious client is brought to the emergency department. Which assessment should be implemented first?

The client's airway should be assessed.

A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on nursing practice standards for safety?

The nurse places the client in a private room with monitored negative air pressure. The client should not be placed in a room with the door open. The nurse must wear the appropriate respirator when caring for the client, but visitors must wear masks. Simply being 3 feet away will not keep the visitor from being exposed to the client. The nurse would use airborne precautions, not droplet precautions when caring for a client diagnosed with tuberculosis.

A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the client should be turned by logrolling. Which statement is correct regarding logrolling?

Use a drawsheet or a friction-reducing sheet to facilitate smooth movement.

During the initial assessment of a newly admitted client, the nurse has clustered the client's range of motion (ROM) with his gait, his bowel sounds with his usual elimination pattern, and his chest sounds with his respiratory rate. The nurse is most likely organizing assessment data according to:

body systems.

When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed?

focus

The nurse is orienting a new client to the facility. The client is told that her preferences and choices would be sought and honored. This represents which expectation of the health care environment?

individualization Individualization is represented by allowing the client to express their choices and preferences and then honoring them. The other choices represent expectations of the health care environment but do not define individualization.

The term metacommunication is best defined as:

interpersonal bridge between verbal and nonverbal communication.

When logrolling a client, the nurse should use supportive devices in turning the client in order to:

maintain the natural alignment of the client's body.

A 55-year-old client has just undergone surgery for a knee replacement. He asks the nurse if he can shave because his face is itching from the stubble. What information is a priority for the nurse to verify prior to shaving the client?

medications listed on the client's medication administration record (MAR)

A home care nurse discusses with a client when visits will occur and how long they will last. In what phase of the nurse-client relationship is this type of agreement established?

orientation phase

A novice nurse is using the assessment technique of auscultation. What assessment finding can the nurse obtain with this method?

presence of peristalsis

The nursing supervisor is presenting the staff nurse with yearly performance evaluations. What type of evaluation is the supervisor presenting to the staff?

process evaluation

A 45-year-old woman is admitted after undergoing a hysterectomy. She has been immobile for 2 days. She has a 20-year history of smoking. She also takes oral estrogen to manage her hot flashes. As a nurse assesses the client, she notices that the client's left leg is dark purple and measures 2 inches (5 cm) larger than her right leg. What is the client most at risk for?

pulmonary embolism

A nurse is caring for a client after a repair of a left femur fracture. The client is immobilized and on strict bed rest and assistance with position change is provided every 2 hours to prevent pressure ulcers. What is the portion of "assistance to prevent pressure ulcers" portion of this statement described as?

rationale; not: nursing intervention

Mr. J. is a 56-year-old man status post admission for a myocardial infarction and coronary artery bypass graft. He is preparing to go home tomorrow. Mr. J. expresses that he feels unprepared to cook heart-healthy foods. The nurse sits with Mr. J. and reviews the heart-healthy nutrition plan, asking him to identify which foods would be appropriate for him to eat. What type of nursing intervention is the nurse engaging in?

supervisory intervention

A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure?

surgical asepsis technique

The nurse has assessed a client and determined that the client has abnormal breath sounds and low oxygen saturation level. The nurse is performing what type of nursing intervention?

surveillance

Nurse Mayweather is auscultating lung sounds. She notes crackles in the LLL which were not present at the start of the shift. Nurse Mayweather is engaged in which type of nursing intervention?

surveillance intervention

A client with limited mobility has outward rotation of the bony protrusions at the head of the femur. Which assistive device would the nurse include in the plan of care?

trochanter rolls

The nurse is performing a physical assessment of a newly admitted client. During the assessment the nurse notices the client grimacing and holding the abdomen. When the nurse asks the client is there is any pain the answer is, "No." What is the best thing for the nurse to do next?

validate the data

The nurse is interviewing a client and is focusing on avoiding comments and questions that will impede communication. Which sentence demonstrates the appropriate use of communication techniques?

when did you first notice the rash on your leg