NUR 101 Exam 2
What is the nurse's responsibility if she suspects her client is being abused?
The nurse is legally bound to report any suspected abuse in the clients. If a nurse does not report suspected abuse, they could be subject to arrest and civil penalties.
An ambulating client informs the nurse, "I feel faint." Which priority action would the nurse take? A. Assist the client to a sitting position. B. Have the client grab the nurse around the neck. C. Splash cold water on the client's face. D. Hold the client upright in a standing position.
A. Assist the client to a sitting position.
The nurse is caring for a group of clients. For which client would the bed rails be left down for safety? A. A confused, disoriented older adult client trying to get out of the bed B. A client who is unresponsive with a severe head injury C. An awake alert client who is ambulatory D. A client who has pneumonia and is able to use the bathroom
A. A confused, disoriented older adult client trying to get out of the bed
The nurse is assisting the client with removal of dentures prior to a surgical procedure and the client requests an explanation of why the dentures have to be removed. Which response by the nurse is best? A. "There is a risk of aspiration or damage to the dentures if they are left in." B. "We will put the teeth in your drinking cup so they won't get lost." C. "The teeth are dirty and a source of potential infection." D. "We have to do this for everyone, not just for you."
A. "There is a risk of aspiration or damage to the dentures if they are left in."
A parent states that since the birth of a sibling the older child is wetting the bed. How should the nurse respond to the parent? A. "This is referred to as regression and is a common defense mechanism." B. "The child is in denial and cannot accept that another child is part of the family." C. "The child is repressing feelings of anger." D. "The child is punishing the parent by soiling."
A. "This is referred to as regression and is a common defense mechanism."
A nurse has administered one unit of glucose to the client as per order. What is the correct documentation of this information? A. 1 Unit of glucose B. 1 bottle of glucose C. one U of glucose D. 1U of glucose
A. 1 Unit of glucose
A client who reports losing sight in both eyes is diagnosed with conversion disorder (functional neurologic symptom disorder) and is admitted to the psychiatric unit. When assisting with the plan of care for this client, which intervention would be most appropriate to include for this client? A. Avoiding focusing on the blindness B. Providing total care C. Stating that the blindness is not real D. Teaching eye exercises to strengthen the eyes
A. Avoiding focusing on the blindness
The nurse observes that a client's respirations are slow and shallow, then gradually become faster and deeper, and then stop, with the cycle then repeating itself. How should the nurse document this type of respiration? A. Cheyne-Stokes respiration B. Eupneic respirations C. Orthopnea D. Dyspnea
A. Cheyne-Stokes respiration
The nurse observes that a clients respirations are slow and shallow, then gradually becoming faster and deeper, and then stop, with the cycle then repeating itself. How should the nurse document this type of respirations? A. Cheyne-Stokes respiration B. Eupneic respirations C. Orthopnea D. dyspnea
A. Cheyne-Stokes respiration
A nurse on a labor and birth unit goes to the cafeteria for lunch with colleagues. One colleague begins talking about a newer staff member and says, "I heard that she does not have any labor and birth nursing experience." Which is the nurse's most appropriate action? A. Discuss the colleague's behavior in private. B. Confront the colleague immediately to prevent causing additional harm. C. Ignore the comment because it is not considered harmful. D. Ask how the colleague knows this information.
A. Discuss the colleague's behavior in private.
A client is having a surgical procedure. Which intervention provided by the nurse can help the client feel safe and aid in postoperative recovery? A. Explain the procedure before surgery. B. Inform the client that they will be alright. C. Call a family member prior to the client entering the surgical suite. D. Make sure all insurance information has been obtained.
A. Explain the procedure before surgery.
The nurse is obtaining a temperature from a client. What symptoms exhibited by the client correlate with a temperature of 102.6 °F? Select all that apply. A. Flushed face B. Hot skin C. Pale skin D. Cold, clammy skin E. Restlessness and chills
A. Flushed face B. Hot skin D. Cold, clammy skin E. Restlessness and chills
The nurse is caring for a client admitted to the hospital with aspiration pneumonia. Which diagnostic label is a priority for this client? A. Impaired gas exchange B. Aspiration risk C. Decreased mobility D. Anxiety
A. Impaired gas exchange
Which of these are step(s) of the evaluation stage of the nursing process? A. Modify goals and interventions B. Collect data C. Plan future care D. Document care E. Recognize data clusters
A. Modify goals and interventions C. Plan future care - Modifying goals and interventions and planning future care are steps of the evaluation stage of the nursing process. - Collecting data and recognizing data clusters are part of the nursing assessment stage. - Documenting care is an essential part of the nursing implementation stage.
A client states, "I feel nauseous," after a surgical procedure. Which is an appropriate dependent nurse action to implement for this client? A. Place an emesis basin where the client can reach it. B. Elevate the head of the bed to 45°. C. Apply a cool, damp cloth to the forehead. D. Administer an antiemetic as ordered.
A. Place an emesis basin where the client can reach it. B. Elevate the head of the bed to 45°. C. Apply a cool, damp cloth to the forehead. D. Administer an antiemetic as ordered.
A nurse discovers that a neighbor is a client on the unit in which the nurse works although the nurse is not assigned to care for that client. The nurse accesses the patients medical record to find out what their diagnosis is. Which action may clients take if they are aware of this type of incident? A. Report the incident as a HIPPA violation. B. Sue the nurse for libel. C. Sue the nurse for negligence. D. Report the nurse for defamation.
A. Report the incident as a HIPPA violation.
The nurse is attempting to make a bed occupied by a client who is obese and on bedrest. Which action is necessary to prevent injury to the nurse? A. Request assistance from a coworker to make the bed. B. Have the client sit in the chair while the nurse makes the bed. C. Avoid changing the sheets since it is difficult. D. Have the client assist with making the bed while in it.
A. Request assistance from a coworker to make the bed.
A parent brings a toddler into the clinic with a strong odor of cigarette smoke on the toddlers clothing. Which information should the nurse discuss with the parent? A. Second hand smoke may cause numerous health related problems B. If the parent continues to smoke around the child, the parent will be reported for child abuse. C. Continuing to smoke around the child can create childhood nicotine addiction. D. Seeing a parent smoke will lead to the child smoking.
A. Second hand smoke may cause numerous health related problems
The nurse obtains a heart rate from a client at a rate of 112. What term should the nurse use when documenting this heart rate? A. Tachycardia B. Bradycardia C. Irregular D. Palpitation
A. Tachycardia
The nurse obtains a heart rate from a client at a rate of 112. What term should the nurse use when documenting this heartrate? A. Tachycardia B. Bradycardia C. Irregular D. Palpitation
A. Tachycardia
A client reports shortness of breath and wheezing and is given a nebulizer treatment with a bronchodilator. Which evaluation recorded by the nurse indicates a positive outcome of the treatment? A. The client has decreased wheezing with no shortness of breath. B. The client requires oxygen at 4 L/m by nasal cannula. C. The client requires transport to a higher level of care unit. D. The client states the need for another treatment.
A. The client has decreased wheezing with no shortness of breath.
The nurse is preparing to obtain an oral temperature from a client. In what situation should the nurse delay taking the temperature for at least 15 minutes? Select all that apply A. The client is chewing gum. B. The client just drank a cup of coffee C. The client just had a chest x-ray D. The client has just finished smoking a cigarette E. The client is chewing tobacco
A. The client is chewing gum. B. The client just drank a cup of coffee D. The client has just finished smoking a cigarette E. The client is chewing tobacco
The nurse is preparing to obtain an oral temperature from a client. In what situation should the nurse delay taking the temperature for at least 15 min? Select all that apply. A. The client is chewing gum. B. The client just drank a cup of coffee. C. The client just had a chest x-ray. D. The client has just finished smoking a cigarette. E. The client is chewing tobacco.
A. The client is chewing gum. B. The client just drank a cup of coffee. D. The client has just finished smoking a cigarette. E. The client is chewing tobacco.
The nurse is caring for a client who has been involved in a motor vehicle crash. Which symptom displayed by the client is the highest priority for the nurse? A. The client is having difficulty breathing. B. The client is bleeding from a laceration on the leg. C. The client states "I have pain in the lower back. D. "The client states "I voided on the stretcher."
A. The client is having difficulty breathing.
In which situation would the nurse revise the nursing care plan? A. The client is losing weight and only eating small amounts of food. B. The wound care provided by the nurse is demonstrating healing of the wound. C. The client's urine in a catheter bag is clear yellow. D. The client's blood pressure has increased from 90/60 to 120/72 mmHg.
A. The client is losing weight and only eating small amounts of food.
The nursing care team is setting short-term goals for a client with end-stage chronic obstructive pulmonary disease. Which short-term goal is the most realistic for this client? A. The client will ambulate 10 ft with 2 L/min of oxygen via nasal cannula without a decrease in oxygen saturation by day 3. B. The client will be able to perform all activities of daily living without dependency on oxygen. C. The client will be able to live independently without assistance. D. The client will be free of shortness of breath.
A. The client will ambulate 10 ft with 2 L/min of oxygen via nasal cannula without a decrease in oxygen saturation by day 3.
The nurse is assisting the nursing team in developing a plan of care for a client in the long-term care facility. After data collection, which step of the nursing process should then be initiated? A. The development of a nursing diagnosis B. The development of goals for care C. Implementation of care for the client D. Ensuring that the care was effective
A. The development of a nursing diagnosis
A home care nurse is caring for a paralyzed client who needs regular position changes and back massages. A person identifying themself as a family friend inquires if they can be of any help to the family. What should be the nurse's response be? A. The nurse should ask the person to talk to the family directly. B. The nurse should invite the person to learn the caring techniques. C. The nurse should state that the family does not need any help. D. The nurse should refer the person to the local social worker.
A. The nurse should ask the person to talk to the family directly.
Clients should be encouraged to remove dentures when sleeping. A. True B. False
A. True
The lack of adequate shelter may not always be life-threatening but it will thwart the ability of a person to progress towards a higher level of needs. A. True B. False
A. True
The nurse is planning for discharge of a client with diabetes. When would the nurse begin the discharge planning of this client? A. When the client is admitted to the healthcare system B. The day the client is to be discharged C. The day before the client is to be discharged D. Before the client is escorted out of the facility
A. When the client is admitted to the healthcare system C. The day before the client is to be discharged D. Before the client is escorted out of the facility
Which methods would be optimal to be sure the client has an understanding of the discharge instructions? Select all that apply. A. Written instructions B. Skill demonstration C. Verbal teaching D. A webinar when the client goes home E. A message delivered via secure patient portal
A. Written instructions B. Skill demonstration C. Verbal teaching D. A webinar when the client goes home
A client's diagnosis of pneumonia requires treatment with antibiotics. The corresponding order in the client's chart should be written as A. moxifloxacin 400 mg daily B. moxifloxacin 400 mg Q.D. C. moxifloxacin 400 mg qd D. moxifloxacin 400 mg OD
A. moxifloxacin 400 mg daily
A nurse in a physician's office has noted on several occasions that one of the physicians frequently obtains controlled drug prescription forms for prescription writing. The physician reports that their spouse has chronic back pain and requires pain medication. One day the nurse enters the physician's office and sees the physician take a pill out of a bottle, and mentions the physician suffers from migraines and it really helps when the physician takes the spouse's pain medication. What type of nurse-physician ethical situation is illustrated in this scenario? A. unprofessional, incompetent, unethical, or illegal physician practice B. disagreements about the proposed medical regimen C. conflicts regarding the scope of the nurse's role D. claims of loyalty
A. unprofessional, incompetent, unethical, or illegal physician practice
A client is to be transferred from the acute care facility to a rehabilitation facility after suffering a stroke. The nurse is gathering papers to send to the accepting facility but is unsure what to send. Which action should the nurse take? A. Send the entire chart. B. Consult the charge nurse. C. Call the transferring physician and ask what to send. D. Only send the demographic information.
B. Consult the charge nurse.
A client is having trouble sleeping. Which nursing intervention should the nurse suggest to the client? A. "Take a warm bath in the early morning, just after rising." B. "Maintain the same schedule for waking and sleeping." C. "Exercise after dinner each night to bring on fatigue." D. "Take frequent naps, especially in the afternoon."
B. "Maintain the same schedule for waking and sleeping."
A newly hired graduate nurse asks her preceptor, "What is a common goal of discharge planning in all care settings?" How does the preceptor correctly respond? A. "It is prolonging hospitalization until the client can function independently." B. "The goal is teaching the client how to perform self-care activities." C. "It is providing the financial resources needed to ensure proper care." D. "The goal is preventing the need for medical follow-up care."
B. "The goal is teaching the client how to perform self-care activities."
Which intervention does the nurse educator include in his or her preparation as an example of primary prevention? A. Administering digoxin to a client with heart failure B. Administering a measles, mumps, and rubella immunization to an infant C. Obtaining a Papanicolaou (PAP) test to screen for cervical cancer D. Using occupational therapy to help a client cope with arthritis
B. Administering a measles, mumps, and rubella immunization to an infant
A client has extensive burns and requires a bed cradle to keep the sheets off the body. Which instructions would the nurse provide the client? A. Leave the side rails down. B. Do not raise or lower the head or feet. C. Do not move at all while in the bed. D. No pillows may be used while the cradle is on the bed.
B. Do not raise or lower the head or feet.
A need at any given level of hierarchy is not urgent to the person if the needs below it are satisfied? A. True B. False
B. False
Assigning a nursing diagnosis can be a function of the registered nurse, LPN or medial assistant. A, True B. False
B. False
Changing a sterile dressing correctly is an example of an intellectual skill. A. True B. False
B. False
Performing oral hygiene often leads to decreased appetite. A. True B. False
B. False
The nursing process is linear and once the problem is resolved the concern is not revisited. A. True B. False
B. False
A licensed practical nurse (LPN) who usually works on a medical-surgical unit is told to report to the cardiac care unit (CCU) for the day because the CCU is short-staffed. The nurse has never worked in a CCU. Which action by the nurse would be most appropriate? A. Call the hospital risk manager to report the request as a violation. B. Identify the tasks that the nurse feels he or she can safely perform on arriving at the CCU. C. Speak to the nursing supervisor about the request for the nurse to go to the CCU. D. Refuse to go to the CCU due to lack of experience.
B. Identify the tasks that the nurse feels he or she can safely perform on arriving at the CCU.
Which priority nursing intervention will assist the client confined to bed with meeting the goal of prevent contractures? A. Turn the client every 2 hr. B. Perform passive range of motion exercises every 2 hr. C. Assist the client with activities of daily living. D. Encourage fluid intake every 2 hr.
B. Perform passive range of motion exercises every 2 hr.
A staff nurse comes to work and accepts the assignment of clients. After a verbal altercation with the nurse manager about the assignment, the nurse states "I quit!" and leaves the facility. Which action may the nurse manager take? A. Call to ask the nurse to come back. B. Report the nurse for abandonment of care. C. Have the police arrest the nurse. D. Let the nurse cool off and come back when ready.
B. Report the nurse for abandonment of care.
The nurse is providing mouth care for an unresponsive client. In which position would the nurse place the client to prevent complications? A. Prone position B. Side-lying position C. Supine with the head of bed elevated 90° D. Trendelenburg
B. Side-lying position
A client has a fever, foul-smelling drainage from a leg wound, and erythema around the wound. Which diagnostic test is a priority for the nurse to observe? A. Chest x-ray B. White blood cell count C. Liver function tests D. Cholesterol levels
B. White blood cell count
A client is admitted with acute chest pain. When obtaining the health history, which question would be most helpful for the nurse to ask? A. "Do you need anything now?" B. "Why do you think you had a heart attack?" C. "How would you rate your pain on a scale of one to ten, with ten being the worst pain imaginable?" D. "Has anyone in your family been sick lately?"
C. "How would you rate your pain on a scale of one to ten, with ten being the worst pain imaginable?"
A client is lying in a hospital bed that is soiled with urine but states to the nurse, "Leave me alone right now." Which response by the nurse is best? A. "I can come back later when you are feeling better." B. "You will have to allow me to change the sheets because they smell terrible." C. "I need to make sure you are clean and dry to prevent irritation to your skin." D. "If you don't let me change your sheets, I will call your care provider."
C. "I need to make sure you are clean and dry to prevent irritation to your skin."
The nurse observes that a bed-confined client's feet are beginning to remain in a plantar flexed position. Which nursing action is appropriate to correct this position? A. Place a pillow under the knees. B. Stand the client on the floor with assistance. C. Apply a slanting footboard to the end of the bed. D. Elevate the foot of the bed.
C. Apply a slanting footboard to the end of the bed.
The nurse is assisting with the admission of an older adult client to the acute care facility. Which priority action would the nurse take to ensure promotion of safety and avoidance of falls? A. Place all four side rails up on the bed. B. Do not allow the client to walk unattended. C. Assist with the performance of a fall-risk assessment. D. Use restraints if the client is disoriented.
C. Assist with the performance of a fall-risk assessment.
A nurse is caring for a female client before surgery. The client states that she is glad that she will not be going through menopause as a result of her surgery and is only having her uterus removed. The nurse reviews the consent form and notes that the surgery is for a total abdominal hysterectomy with a salpingo-oophorectomy. What should the nurse do in this situation? A. No action is needed because the client is likely correct and knows what the surgery entails. B. Inform the client that menopause may occur from the removal of the uterus. C. Contact the surgeon to explain that the client needs further clarification regarding surgery. D. Place a note on the front of the chart telling the surgeon to speak with the client before surgery.
C. Contact the surgeon to explain that the client needs further clarification regarding surgery.
The licensed practical nurse (LPN) prepares a client's regularly scheduled prescribed medications. The client refuses to take them. Which action should the LPN take? A. Explain to the client about the need for the medications because the health care provider prescribed them. B. Tell the client that refusing to take the medications will worsen the current condition. C. Document in the client's medication administration record that the medications were refused. D. Explain to the client's family that the client refused to take the medications.
C. Document in the client's medication administration record that the medications were refused
The nurse determines that a client requires a partial bath. In order to promote self-esteem, which action would the nurse take? A. Allow the client to rest while the nurse completes the full bath. B. Inform the client that they will need to complete the bath. C. Encourage the client to do as much of the bath as possible. D. Inform the client that if the bath cannot be completed, it can be done later.
C. Encourage the client to do as much of the bath as possible.
A nurse is caring for a 7-year-old child with Down syndrome. What action should the nurse take when assisting with the plan of care for this child? A. Plan interventions at the developmental level of a 7-year-old because that is the child's age. B. Plan interventions at the developmental level of a 5-year-old because the child with Down syndrome has developmental delays. C. Evaluate the child's current developmental level and plan care accordingly. D. Direct all teaching to the parents because the child cannot understand.
C. Evaluate the child's current developmental level and plan care accordingly.
The charge nurse requests that the nurse provide oral hygiene every 2 hr for a client with a nasogastric tube. Which part of the nursing care plan does this describe? A. Assessment B. Planning C. Implementation D. Evaluation
C. Implementation
A nurse is seen accessing a client's medical record in an area where she doesn't provide care. Which action by the nurse is best? A. No action is necessary. B. Ask the nurse why she's accessing the medical record and ask her to leave the client care area. C. Notify the charge nurse and nursing supervisor of the incident. D. Notify security and the client's physician of the incident.
C. Notify the charge nurse and nursing supervisor of the incident.
A client undergoing a brain computed tomography (CT) scan because of continual migraine headaches is placed in the CT scanner and suddenly reports having palpitations, shortness of breath and shaking. What is the client most likely experiencing? A. Allergic reaction B. Myocardial infarction (MI) C. Panic attack D. Hypoglycemic episode
C. Panic attack
Which does the nurse determine is the first step in the planning process? A. Establish expected outcomes. B. Select the nursing intervention. C. Set priorities. D. Write the care plan.
C. Set priorities.
The nurse is collecting data from a client in the clinic. Which observation documented by the nurse is an olfactory observation? A. The client's skin is warm and dry. B. The client has cyanosis around the lips. C. The client's breath has a fruity odor. D. The client wheezes bilaterally when the chest is auscultated.
C. The client's breath has a fruity odor.
A nurse can help a client in meeting self-esteem needs by: A. assisting to get enough sleep B. explaining the procedures, treatments, or medications C. rewarding the client's progress D. feeding the client E. reporting signs of abuse
C. rewarding the client's progress A nurse can help clients to regain positive self-esteem by encouraging independence and, consequently, rewarding progress.
The unlicensed assistive personnel tells the nurse that it is unreasonable to expect a response to all call lights within 10 minutes. Which statement by the nurse best illustrates appropriate assertive behavior by a supervisor? A. "I will have to report to the supervisor if you can't do it." B. "All clients have a right to compassionate and timely care." C. "I will take care of any client needs that you can't provide." D. "Let's discuss how we can meet our clients' needs."
D. "Let's discuss how we can meet our clients' needs."
A nurse needs to enter into the computer the time the client took medication. However, the time is written in the military format, and the computer accepts only the traditional format. How should the nurse enter the time in the computer if the client took medication at 1530 hours? A. 03:00 p.m. B. 05:30 a.m. C. 03:30 a.m. D. 03:30 p.m.
D. 03:30 p.m.
Family members of a client report to the nurse that they are exhausted and it is difficult taking care of a dependent family member. Which approach by the nurse is in the client's best interest? A. Ask the client what he or she would like to do. B. Tell the family members to discuss it among themselves. C. Tell the family the client should go to a nursing care facility. D. Call a family conference and ask social services for assistance.
D. Call a family conference and ask social services for assistance.
A client requests the nurse to clean the earpieces of the hearing aid. Which action would the nurse take to be sure it is cleaned appropriately? A. Clean the earpieces with alcohol. B. Soak the earpieces in hydrogen peroxide. C. Wipe the earpieces with disinfectant wipes. D. Clean the earpieces with Q-tips dipped in saline.
D. Clean the earpieces with Q-tips dipped in saline.
A client has a sacral wound, is confused and keeps trying to climb out of bed, is severely dehydrated, and hasn't had a BM in 2 days. Which problem is the priority? A. Confusion B. Fall risk C. Sacral Wound D. Dehydration E. Constipation
D. Dehydration
The nurse is caring for a client that has been confused and climbing out of bed. Which action should the nurse take if the nurse must leave the room to take care of another patient? A. Place all four side rails up and come back and check on the patient when finished with the other task. B. Place the client in soft wrist restraints so the client will not get out of bed. C. Inform the client not to get out of bed. D. Don't leave the client alone and request that another nurse sit one on one with the client.
D. Don't leave the client alone and request that another nurse sit one on one with the client.
A client is being treated for an infected sacral pressure wounds. The nurse has performed prescribed wound care twice a day for 5 days. Which part of the nursing process should be performed next? A. Development of the nursing diagnosis B. Development of goals C. Implementation of nursing care D. Evaluation of the care provided
D. Evaluation of the care provided
The child of an alert and oriented elderly client asks what parent's most recent blood glucose level was. What is the nurse's best response? A. Tell the client's child the blood glucose level because this test is performed on the nursing unit. B. Ask the client's child if she has her parent's permission to access the parent's health information. C. Have the child sign a "Disclosure of Health Information" form prior to giving the child the information. D. Explain that this information cannot be disclosed without the client's permission.
D. Explain that this information cannot be disclosed without the client's permission.
Which of these is not a step in nursing implementation? A. Putting the nursing care plan into action B. Continuing the collection of data C. Communicating care with the healthcare team D. Identifying strengths and problems E. Documenting care
D. Identifying strengths and problems Nursing implementation includes the following steps: Putting the nursing care plan into action, continuing the collection of data, communicating care with the healthcare team, and documenting care. Strengths and problems are identified in the assessment stage.
The nurse is caring for a client who is having difficulty with mobility. Which action taken by the nurse can assist the client with regaining mobility? A. Promote self-care activities. B. Perform tasks for the client. C. Reassure the client that they will not fall if they get up. D. Perform passive range of motion exercises every hour.
D. Perform passive range of motion exercises every hour.
A nurse is caring for a client who has just had a modified radical mastectomy with immediate reconstruction. What action should the nurse take to assist the client with coping? A. Tell the client's spouse or partner to be supportive while she recovers. B. Encourage the client to proceed with the next phase of treatment. C. Recommend that the client remain cheerful for the sake of her children. D. Provide a referral to the Cancer Society or another support program.
D. Provide a referral to the Cancer Society or another support program.
The client has been in the hospital for treatment of pneumonia with periods of high fever. The nurse has cared for the client for 2 days. The client was afebrile for 24 hr the day before and now has a fever of 101 °F. What type of fever does the nurse recognize the client is experiencing? A. Remittent B. Constant C. Crisis D. Relapsing
D. Relapsing
The client has been in the hospital for treatment of pneumonia with periods of high fever. The nurse has cared for the client for two days. The client was afebrile for 24 hours the day before and now has a fever of 101 degrees F. What type of fever does the nurse recognize the client is experiencing? A. Remittent B. Constant C. Crisis D. Relapsing
D. Relapsing
A client who has diabetes states to the nurse, "I try to remove the calluses from my feet." Which information would the nurse be sure to discuss with the client to avoid complications? A. Use a sharp razor to remove the calluses. B. Use a salicylic acid solution to dissolve the calluses. C. Use a nail file to trim them. D. Use oil or a lotion to soften them only.
D. Use oil or a lotion to soften them only.
The nurse is changing soiled sheets on a client's bed. Which action would the nurse take to avoid injury? A. Throw the soiled sheets on the floor to avoid having to turn to place them in a bag. B. Bend at the waist when moving the sheets under the client. C. Keep the bed in the lowest position while making the bed. D. Use proper body mechanics at all times when changing the sheets.
D. Use proper body mechanics at all times when changing the sheets.
The nurse is preparing to transfer a client with obesity from the bed to the chair. Which action by the nurse is best to avoid injury to the nurse and the client? A. Use a team approach for lifting the client. B. Lift the client using a swivel and pivot motion. C. Leave the client in the bed because the client is too large to get up. D. Utilize a mechanical lift for the transfer.
D. Utilize a mechanical lift for the transfer.
A licensed practical nurse (LPN) is working on a wing of a medical-surgical unit that is also staffed with a registered nurse and a certified nursing assistant (CNA). When providing care, which task would be most appropriate for the LPN to delegate to the CNA? A. obtaining vital signs of a client who just returned from a colonoscopy B. feeding a client for the first time after he experienced a stroke C. increasing the oxygen flowmeter to 4 L/minute D. encouraging a client to drink fluids
D. encouraging a client to drink fluids
A client newly diagnosed with type 2 diabetes is admitted to the metabolic unit for treatment initiation and education. Which information should the nurse reinforce to this client as a goal for treatment? A. maintenance of blood glucose levels between 180 and 200 mg/dL B. smoking reduction but not complete cessation C. an eye examination every 2 years, until age 50 D. exercise and a weight-reduction diet
D. exercise and a weight-reduction diet
The nurse obtains laboratory results on assigned clients during morning report. Which results needs to be immediately reported to the health care provider? A. hemoglobin 13.6 mg/dL B. creatinine level 0.6 mg/dL C. glucose level 98 mg/dL D. potassium level 6.2 mg/dL
D. potassium level 6.2 mg/dL
Is the following statement true or false? It is always safer to have side rails up.
False In some cases, having the side rails up can be more dangerous than having them down. For example, an elderly client may continually try to crawl out of bed. In this case, he or she might crawl over the side rails, making a potential fall worse than if it were just from the lower level of the bed.
Why is it important that nurse document breaks or signs of irritation in the client's skin on admission to the facility?
It is vital to carefully and completely document any breaks or signs of irritation in the client's skin on admission to the facility. In nearly all cases, if a client's skin breaks down after admission, the facility is considered to be responsible. In most cases, third-party payors will not reimburse the facility for costs incurred related to skin breakdown that was not present when the client was admitted.
What should the nurse keep in mind when handling used bed linens?
Linens may be soiled with body fluids. To prevent the spread of microorganisms, never shake linens or put them on the floor. Soiled linens from the bed or floor can contaminate the uniform, which may come in contact with other clients.
A 15-year-old client who is experiencing lower abdominal cramps admits that she has had an abortion in the recent past, of which her family has no knowledge. Is the nurse required to inform her parents as she is under age?
The nurse must protect the confidentiality of the client, never revealing any information previously unknown to the family without the client's permission.
In what circumstances should an arm not be used for blood pressure measurement?
The nurse should not use the client's arm for blood pressure measurement if it is compromised in any way - such as: - Recent mastectomy - Arteriovenous shunt or fistula - Lymphedema - Injury/wound - Cast/Splint - IV line/saline lock - If both arms are unavailable, use of an alternate site, such as the leg, is necessary.
What effect does the mother smoking have on the risk of sudden infant death syndrome (SIDS) in her children?
The risk of SIDS doubles. Pregnant women who smoke also increase the chances of having a low-birth-weight baby, preterm births, and stillborn babies.
Explain how the steps of the nursing process will take place over the course of a day.
Though the shift will usually start with assessment, the nursing process is dynamic and ever-changing. Although it contains definite steps, these steps often overlap. Sometimes, they all occur at once.
Why should only specially trained people ever cut the toenails of a client with diabetes?
To avoid accidental injury to soft issues, the nurse should not cut a client's toenails if the client has diabetes or hemophilia or very thickened nails. Wounds heal very slowly in clients with diabetes or hemophilia. Very thick nails often need to be cut by a specially trained person using special equipment and techniques.
Is the following statement true or false? The nursing process highlights the differences in roles between licensed personnel and nonlicensed personnel.
True The nursing process not only includes the actions involved in tasks but also integrates critical thinking. Unlicensed personnel are required to know how to take vital signs. In addition to how, the licensed nurse must also know why the vital signs are important and what is the relationship of the numbers obtained with the condition of the client.
Which step of the nursing process allows the nurse to identify priorities and collect data? A. Nursing assessment B. Nursing diagnosis C. Planning D. Implementation E. Evaluation
a. Nursing assessment The nurse identifies priorities, collects data, and updates database during the assessment phase of the nursing process.
Is the following statement true or false? Discharge planning begins on admission of the client into the facility.
True The client and family cannot be expected to remember a large amount of teaching at one time, especially just as the client is leaving the facility. Discharge planning may include written instruction, skills demonstration, and/or verbal teaching. The client, the family, and one or more significant persons may be included in the discharge planning.
A person's pulse may increase over baseline due to which of the following reasons? Select all that apply. a. Stimulants such as caffeine b. Recent exercise c. Emotional stress d. Alcohol e. Hypothermia f. Sleep
a. Stimulants such as caffeine b. Recent exercise c. Emotional stress
In which of the following situations would an oral temperature be contra-indicated? a. A client has an active seizure disorder b. A client has diarrhea c. A client is a smoker d. A client is receiving an oral antibiotic
a. A client has an active seizure disorder
A client is breathing very deep, gasping breaths at a normal to high rate despite being at rest. This kind of respiration is known as: a. Kussmaul respiration b. Cheyne-Stokes respiration c. Biot's respiration d. Dyspnea
a. Kussmaul respiration
In which of the following situations should the nurse wait before taking a client's oral temperature? a. The client has been chewing gum b. The client has been sitting in the chair without a robe on c. The client looks flushed d. The client has just come back from walking in the hallways
a. The client has been chewing gum
Blood pressure is determined by which of the following? Select all that apply. a. The strength of cardiac contractions b. The stiffness of the blood vessels c. The amount of circulating blood volume d. The amount of iron in the blood e. The number of times the client's heart beats per minute
a. The strength of cardiac contractions b. The stiffness of the blood vessels c. The amount of circulating blood volume
A client questions the nurse who is taking her blood pressure, "Why don't you just pump the cuff up to 180, like all the other nurses do instead of this two-step method?" What should the nurse respond? a. Pumping the cuff up higher than it needs to go can lead to an inaccurately low blood pressure reading b. Pumping the cuff up higher than it needs to go can lead to an inaccurately high blood pressure reading. c. This method is required by JCAHO d. I don't know, it's just the way I was taught.
b. Pumping the cuff up higher than it needs to go can lead to an inaccurately high blood pressure reading.
If a client complains of a headache and fever, but she has not recorded the temperature. Is this objective or subjective data?
subjective This data is subjective because it is based on the client's feelings. If the temperature is measured by a thermometer then, that data would be objective.
