NUR 112 Practice Assessment

Cranberry juice

A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the lunch tray?

a. Broth b. Grape juice e. Lemon gelatin

32. A nurse is caring for a client who is postoperative following an appendectomy. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse offer the client? Select all that apply. a. Broth b. Grape juice c. Nonfat milk d. Custard e. Lemon gelatin

a. Feedback

66. A nurse is teaching a client about the physical effects of chemotherapy. Following the teaching, the nurse asks the client to describe one physical effect. The nurse is focusing on which of the following elements of the communication process? a. Feedback b. Channel c. Environment d. Message

a. Documentation is a communication tool for the interprofessional health care team

10. A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? a. Documentation is a communication tool for the interprofessional health care team b. Documentation provides information to the client about financial charges for care provided c. Documentation provides information for a client audit d. Documentation allows providers to monitor the nurse's activities

a. Removing the client's dentures c. Palpating for pedal edema d. Counting radial pulse

100. A nurse is performing care activities for a client in the zone of touch that requires his consent. Which of the following activities should the nurse perform in this zone? Select all that apply. a. Removing the client's dentures b. Checking capillary refill beneath the client's fingernail c. Palpating for pedal edema d. Counting radial pulse e. Assessing a mole on the client's shoulder

c. Washes and rinses her hands for 10 seconds

11. A nurse is orienting a new assistive personal (AP) to the unit. For which of the following actions should the nurse intervene? a. Wears a gown when entering the room of a client who requires contact precautions b. Dons gloves to empty a urinary drainage device c. Washes and rinses her hands for 10 seconds d. Wears a respirator mask when entering the room of a client who requires airborne precautions

c. Industry vs inferiority (a school age child (6-12) is in this stage of development)

12. A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. Which of the following of Erikson's developmental stages should the nurse consider in the planning? a. Autonomy vs shame and doubt b. Initiative vs guilt c. Industry vs inferiority d. Identity vs role confusion

b. Assigning tasks to an AP (delegation is considered indirect care)

13. A nurse is implementing direct nursing care for a group of clients in an acute care facility. Which of the following actions by the nurse is considered an indirect nursing care activity? a. Determining the client's length of stay b. Assigning tasks to an AP c. Providing anticipatory guidance to a client in crisis d. Establishing the client's secondary medical diagnoses

b. Notify the surgeon that the client wishes to withdraw informed consent for the procedure (the client has the right to withdraw consent therefore the surgeon should be the one notified of the request)

14. A nurse has completed an informed consent form with a client. The client then states, "I have changed my mind and do not want to have the procedure done." Which of the following actions should the nurse take? a. Remind the client that a signed informed consent form is a legally binding document b. Notify the surgeon that the client wishes to withdraw informed consent for the procedure c. Inform the surgical team to cancel the client's surgery d. Proceed with the preparation of the patient's surgical procedure

b. Asking for an explanation

15. A nurse is caring for a client who has a mental health disorder. The client asks about his medications and their effects. The nurse asks why the client needs to know this. Which of the following nontherapeutic communication techniques is the nurse using? a. Changing the subject b. Asking for an explanation c. Behaving defensively d. Arguing

a. I'll apply ankle to my ankle today and tomorrow (the RICE acronym outlines how to treat an ankle sprain: rest, ice, compression, elevation)

16. A nurse is discharging a client who has come to the outpatient clinic with an ankle sprain. Which of the following statements should the nurse identify as an indication that the client understands the discharge information? a. I'll apply ankle to my ankle today and tomorrow b. I'll rewrap my ankle starting from the knee down c. I'll bear weight on my ankle for 10 minutes every hour d. I'll put a heating pad on my ankle at bedtime tonight

d. I have a set of my brothers' crutches in the basement I can also use (the client should not use crutches that belong to someone else; the crutches must fit body dimensions)

17. A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs further teaching? a. I will keep spare crutch tips handy b. I will bear the weight of my body on my hands c. I will inspect my crutches everyday for signs of wear d. I have a set of my brothers' crutches in the basement I can also use

a. This service began with the client's admission to the hospital

18. A nurse is caring for an older adult client who has a fractured hip and will require rehab care. The cleint's family asks the nurse for info about this type of care. Which of the following explanations should the nurse provide? a. This service began with the client's admission to the hospital b. This service focuses on teaching the primary caregiver to meet the client's needs c. The emphasis is on the client's complete recovery from the illness or injury d. Services are centered in long-term care facilities

a. Point out inconsistences in the client's behavior (a nurse using confrontation helps the client become aware of inconsistencies in his feelings, attitudes, beliefs, and behaviors. It also helps the client deal with issues that are important to him)

19. A. nurse is caring for a client who is not cooperating with his care and demonstrates defiant behavior. The nurse chooses to confront the client. Which of the following approaches should the nurse use when using confrontation? a. Point out inconsistences in the client's behavior b. Change the subject when the client behaves defiantly c. Use an aggressive tone of voice d. Wait to discuss the behavior in the presence of others

a. Remove all metal necklaces

54. As part of an annual physical examination a nurse is preparing a client to undergo a chest x-ray. Which of the following instructions should the nurse give to the client prior to the procedure? a. Remove all metal necklaces b. Take several shallow breaths during the procedure c. Do not eat or drink anything the morning of the test d. Expect minor discomfort after the procedure

a. They are more direct when discussing issues (men focus on issues and discuss them more directly and readily than women do)

20. A nurse is engaging in relationship counseling with a male client. Which of the following is a characteristic of men that the nurse should consider when beginning the nurse-client relationship? a. They are more direct when discussing issues b. They are likely to wait for others to initiate conversation c. They tend to use more verbal communication d. They disclose more personal information

a. 208 (a client who has TB requires airborne precautions; that means a private room with negative air pressure flow)

21. A charge nurse is planning a room assignment for a client who has a productive cough, a questionable x-ray, and a positive Mantoux test. Room 208 is a private, negative pressure airflow room; room 212 is a semi private, positive airflow pressure room; 214 is a negative pressure room, a semi private room; and room 216 is a private positive-pressure airflow room. To which of the following rooms should the nurse assign the client? a. 208 b. 212 c. 214 d. 216

a. Education c. Gender d. Perception

22. A nurse is having difficulty caring for a client due to variables affecting the communication process. Which of the following should the nurse identify as an interpersonal variable? (Select all that apply) a. Education b. Feedback c. Gender d. Perception e. Time

a. Bathe a client who had an amputation 2 days ago b. Assist a client to ambulate using a gait belt e. Feed a client who had a stroke 3 months ago

31. A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to AP? Select all that apply. a. Bathe a client who had an amputation 2 days ago b. Assist a client to ambulate using a gait belt c. Review a low-sodium diet for the client who has hypertension d. Explain oral hygiene to a client receiving chemo e. Feed a client who had a stroke 3 months ago

c. The nurse may serve as a witness to informed consent for organ donation (nurses may witness the consent for organ donation after a specially trained professional requests consent)

23. A nurse is preparing an education presentation about organ donation for a group of newly licensed nurses. Which of the following info should the nurse include? a. The nurse caring for the client at the time of death requests organ donation b. Donation costs are the responsibility of the donor's family and estate c. The nurse may serve as a witness to informed consent for organ donation d. Clients are placed on artificial life support before organ and tissue donation can occur

a. I'll sit with my knees lower than my hips (client should sit with knees slightly higher than their hips to prevent injury)

24. A nurse in a clinic is teaching a group of clients about preventing low back pain and injury. Which of the following statements should the nurse identify as an indication that the client requires further clarification? a. I'll sit with my knees lower than my hips b. I'll do exercises that strengthen my abdominal muscles c. I'll wear low heeled shoes from now on d. I'll carry heavy objects close to my body

d. Places clean linen that touched the floor in the soiled linen bag

25. A nurse in a long-term care facility is observing an AP changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the AP understands the principles of infection control? a. Shakes the soiled linen to remove any toilet paper remnants b. Places the soiled linen in the floor before bagging it c. Holds the soiled linen against her body while carrying it to the linen bag d. Places clean linen that touched the floor in the soiled linen bag

d. Decreased calcium excretion (prolonged immobility leads to the breakdown of bone tissue; result is decreased calcium excretion)

26. A nurse is caring for a client who has emphysema and has difficulty with mobility. The client receives home health care and spends most of his day in a reclining chair. Which of the following physiological responses to prolonged immobility should the nurse expect? a. Increased insulin production b. Decreased RBC production c. Decreased sodium excretion d. Decreased calcium excretion

c. Provide the client with a diet high in protein (inadequate intake of protein, iron, vitamins, and calories increase the risk for skin breakdown)

27. A nurse is caring for an older client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? a. Reposition the client every 3 hr b. Massage any bony prominences to promote circulation c. Provide the client with a diet high in protein d. Apply cornstarch to keep the skin dry

b. Wash the area of the puncture thoroughly with soap and water (the greatest risk to this client is injury from any bloodborne pathogens on the needle therefore the first action the nurse should take is to provide immediate first aid)

28. A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first? a. Report the incident to the charge nurse b. Wash the area of the puncture thoroughly with soap and water c. Complete an incident report d. Go to employee health services

b. Reporting laboratory findings to a member of the client's family (the only people allowed to receive info are those that the client has given permission and those that are working with the client and their case)

29. A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following actions is an example of a violation of confidentiality? a. Discussing a client's surgical procedure with the nurse manager b. Reporting laboratory findings to a member of the client's family c. Notifying the provider of physical exam findings d. Identifying the client by name when making a referral for home health services

b. Perform the Heimlich maneuver

30. A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. Which of the following actions should the nurse take? a. Observe the client before taking further actions b. Perform the Heimlich maneuver c. Assist the client to the floor and begin mouth-to-mouth d. Slap the client on the back several times

d. Use soap and water to wash the catheter after each use

33. A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has a benign prostatic hyperplasia. Which of the following instructions should the nurse include? a. Perform catheterization when you recognize the urge to void b. Hold the penis at a 30 to 45 degree angle when inserting the catheter c. Inflate the balloon when the urine flow stops d. Use soap and water to wash the catheter after each use

c. Consensus evolves in this stage (consensus occurs and cooperation develops during the norming stage)

34. A nurse is discussing the norming stage of the group development process with a student nurse. Which of the following statements by the student indicates understanding of the discussion? a. This stage involves constructive efforts on the part of the group members b. This stage is when testing occurs to identify boundaries of interpersonal behaviors c. Consensus evolves in this stage d. Resistance is evident as subgroups form in this stage

c. Discard the tablet and obtain another dose of medication

35. A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Which of the following actions should the nurse take? a. Use the tablet's packaging to pick it up from the counter b. Wash the tablet off with alcohol and place it in a clean medicine cup c. Discard the tablet and obtain another dose of medication d. Place the tablet directly into a medication cup

d. Reflection

36. A nurse is caring for a client who is discussing his post-traumatic stress disorder and states: "Everyone thinks you should be able to put it out of your mind. It happened so long ago - just get over it!" the nurse responds: "It must be very frustrating to encounter this kind of attitude." The nurse is using which of the following therapeutic communication techniques? a. Clarifying b. Focusing c. Paraphrasing d. Reflection

c. Leave a nightlight on in the client's room (night vision may be impaired in older clients; a nightlight may help client recognize their surroundings and decrease the likelihood of disorientation)

37. A nurse is caring for an older client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take? a. Limit the client's fluid intake in the evening b. Obtain a bedside commode for the client's use c. Leave a nightlight on in the client's room d. Put the side rails up and tell the client to call the nurse before voiding

d. Two nurses using a friction-reducing device (reduces the risk of injury to the nurses and to the client; nurses can use a draw sheet as a friction-reducing device)

38. A nurse is preparing to move a client who is only partially able to assist up in a bed. Which of the following methods should the nurse plan to use? a. One nurse lifting as the client pushes with his feet b. Two nurses lifting the client under the shoulders c. One nurse lifting the client's legs as the client uses a trapeze bar d. Two nurses using a friction-reducing device

d. Use attentive listening with the client (when establishing presence, eye contact, body language, voice tone, listening, and reflection convey openness and understanding)

39. A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. Which of the following actions should the nurse take? a. Focus on the client's present circumstances instead of his personal stories b. Verbalize understanding of how the client feels c. Offer the client personal thoughts and beliefs d. Use attentive listening with the client

c. Contact the provider to question the dosage (when a nurse believes there is an error in a prescription, the nurse must question the provider)

4. When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Which of the following actions should this nurse take? a. Contact the pharmacy and confirm that the dosage is safe to administer b. Ask another nurse to verify that the dosage is appropriate for the client c. Contact the provider to question the dosage d. Inform the charge nurse and administer the dose of the medication the provider prescribed

d. Water heater temp 54.4 C (130 F) (no higher than 49 or 120) e. Throw rugs

40. A home health nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse identify as a safety risk? Select all that apply. a. Bathtub with rails b. Electric cords behind the furnitrure c. Raised toilet seats d. Water heater temp 54.4 C (130 F) e. Throw rugs

d. I will take my medications at the first sign of an attack

41. A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching? a. I will wear gloves when removing food from the freezer b. I will try to anticipate and avoid stressful situations when possible c. I will complete the smoking cessation program I started d. I will take my medications at the first sign of an attack

d. To identify delayed gastric emptying (the nurse should measure the amount of unabsorbed formula from the previous feeding to identify delayed gastric emptying; if it is delayed the nurse should avoid overfeeding the client and causing gastric distention)

42. A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? a. To confirm the placement of the NG tube b. To remove gastric acid that might cause dyspepsia c. To determine the client's electrolyte balance d. To identify delayed gastric emptying

a. Auscultate breath should at least ever 2 hr (priority action the nurse should contribute to the plan of care when using the ABC approach to client care in auscultating breath sounds to determine the client's need for suctioning; with inactivity, secretions can pool in the airways, diminishing breath sounds and causing crackles and dyspnea)

43. A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to include in the client's plan of care? a. Auscultate breath should at least ever 2 hr b. Perform range of motion (ROM) exercises at least 2-3 times daily c. Make sure the client has an intake of 2,000-3,000 mL of fluid/day d. Apply antiembolic stockings

d. I will place a bath seat in my shower to use when I bathe

44. A nurse is teaching a client who has a history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. I will keep my walker at the end of my bed b. I will keep the fluorescent ceiling light on in my room at night c. I will place an area rug at the entry of my bathroom d. I will place a bath seat in my shower to use when I bathe

b. It's unfortunate that I have to be in the hospital for this treatment (TENS units are portable; they can be used at home)

45. A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements should the nurse identify as an indication the client needs further teaching? a. I wish I didn't have to attach the electrodes to my skin b. It's unfortunate that I have to be in the hospital for this treatment c. I'll need to shave the hair off the skin where I place the electrodes d. I hope I don't have to take as many pain pills

d. Left forearm (allows for easy access and doesn't interfere with the IV catheter)

46. A nurse is preparing to obtain a blood specimen from a client by venipuncture. The client is receiving IV fluids through an IV catheter inserted in the basilic vein on the right forearm. Which of the following sites should the nurse plan to use to obtain the blood specimen? a. Left upper forearm b. Right forearm c. Foot d. Left forearm

b. Narrative interaction (involves asking a client to share personal stories so the nurse can better understand the context of a client's life in the working phase of a nurse-client relationship)

47. A nurse asks a client to share personal stories. Which of the following types of intervention is the nurse using to promote the development of the nurse-client relationship? a. Symbolic communication b. Narrative interaction c. Hand-off technique d. Social conversation

a. Report of feeling pressure b. Tenderness over the symphysis pubis c. Distended bladder d. Voided 30 mL frequently

48. A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? Select all that apply. a. Report of feeling pressure b. Tenderness over the symphysis pubis c. Distended bladder d. Voided 30 mL frequently e. Dysuria

c. Request a tray without pork

49. A nurse is developing a plan of care for a client who practices Islam. Which of the following actions should the nurse include in the plan? a. Serve food that have a hot/cold balance b. Serve milk products separately from meals c. Request a tray without pork d. Remove tea and coffee from meal trays

a. Occupational therapist (an occupational therapist assists clients who have physical challenges to use adaptive devices and strategies to help with self-care activities such as feeding)

5. A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive devices. The nurse should initiate a referral with which of the following members of the interprofessional health care team? a. Occupational therapist b. Social worker c. Registered dietician d. Speech pathologist

b. Provide an adaptive feeding device for the client

50. A nurse is caring for a client who has limited hand movement. Which of the following actions should the nurse take to assist the client with feeding? a. Place the client in a lateral position b. Provide an adaptive feeding device for the client c. Initiate a liquid diet for the client d. Arrange the food groups clockwise on the client's place

b. I'll use the cleansing wipes from the front to back

51. A nurse instructs a female client about collecting a midstream urine sample. Which of the following client statements indicates an understanding of the procedure? a. I'll urinate a little then stop b. I'll use the cleansing wipes from the front to back c. I'll clean the inside of the container with a wipe d. I'll use each cleansing wipe twice

d. I decline this opportunity at this time (assertive because it contains an "I" statement and it is clear and firm)

52. A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. Which of the following statements should the nurse make? a. It's just not the right time for me to do this b. Everyone knows there are others who can chair this committee better than me c. Can you tell me why you chose me? d. I decline this opportunity at this time

b. Reach around the pack and open the top flap away from the body

53. A nurse is preparing a sterile field. Which of the following actions should the nurse perform when opening the sterile pack? a. Place the pack on a sterile work surface b. Reach around the pack and open the top flap away from the body c. Open the right flap with the left hand d. Move to the opposite side of the pack and open the fourth flap

b. I will come back later and we can talk (offers herself to client which encourages open communication)

55. A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. The client says, "go away, no one can help me." Which of the following statements should the nurse make? a. Everything will be okay b. I will come back later and we can talk c. Why are you crying? d. Do you think crying will help?

a. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen (nurse should remove all wound exudate and any residual antimicrobial ointment or cream to avoid altering the culture results)

56. A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? a. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen b. Irrigate the wound with an antiseptic prior to obtaining the specimen c. Include intact skin at the wound edges in the culture d. Swab an area of skin away from the wound to identify the usual flora

a. Elicit info from the client (obtaining info from the client is a component of orientation phase)

57. A nurse is caring for a client in the orientation phase of the nurse-client relationship. Which of the following communication techniques should the nurse use during this phase? a. Elicit info from the client b. Encourage the client to use self-exploration c. Review the client's progress toward personal objectives d. Talk with others who have info about the client

b. I can detect the presence of carbon monoxide by a metallic odor

58. A nurse is teaching a client about carbon monoxide poisoning. Which of the following statements should the nurse identify as an indication that the client needs further instruction? a. A high concentration of carbon monoxide can cause death b. I can detect the presence of carbon monoxide by a metallic odor c. I should purchase a carbon monoxide detector for my home d. Breathing in carbon monoxide can cause headaches and nausea

c. Take the client to the bathroom every 2 hr (this establishes a regular pattern of toileting and the client learns to trust that the staff will place value on his bladder-training needs)

59. A nurse in a long-term care facility is caring for an older client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior? a. Remind the client to tell the nurse when he has to urinate b. Use adult diapers to prevent frequent clothing changes c. Take the client to the bathroom every 2 hr d. Request a prescription for an indwelling urinary catheter

c. Interpersonal (interpersonal communication is face-to-face interaction with another person. It results in an exchange of ideas, problem solving expression of feelings, decision making, and personal growth)

6. A nurse receives a client care assignment from the charge nurse that he believes is unfair. The nurse voices his concern to the charge nurse. The nurse is using which level of communication at this time? a. Transpersonal b. Intrapersonal c. Interpersonal d. Public

c. I will begin upon the client's admission to the facility (effective discharge planning must begin upon admission of the client to the facility)

60. A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understands when discharge plans should be implemented? a. I will begin 48 hr before the client's discharge b. I will begin once the client's discharge order is written c. I will begin upon the client's admission to the facility d. I will begin once the client's insurance company approves discharge coverage

b. The area surrounding the insertion site feels warm to the touch

61. A nurse is working with an LPN to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site? a. The infusion rate has stopped but the tubing is not kinked b. The area surrounding the insertion site feels warm to the touch c. There is fluid leaking around the insertion site d. There is no blood return when the tubing is aspirated

c. I will cover the catheter so he cannot see it (using stockinette or clothing to cover the IV insertion site is an appropriate distraction technique and might steer the client's attention away from the catheter)

62. A nurse is caring for a client who frequently attempts to remove his IV catheter. A family member requests that the nurse apply restraints. Which of the following responses should the nurse make? a. I'll provide more stimulation in his environment b. I will call the doctor and get the prescription c. I will cover the catheter so he cannot see it d. Let's wait until tonight to see if he continues his behavior

a. Explore the client's feelings

63. A nurse is caring for a client who expresses anxiety about his impending surgery. Which of the following actions should the nurse take? a. Explore the client's feelings b. Discuss the competency of the surgeon c. Review another client's similar surgical experience d. Talk with the client's partner

b. Include any relevant statements the client made about the ulcer

64. A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? a. Document what the nurse believes was the cause of the ulcer development b. Include any relevant statements the client made about the ulcer c. Document in the client's medical record that she completed an incident report d. Question the charge nurses about the care deficits that might have contributed to the ulcer's development

b. Sudden attacks of sleep c. Hallucinations at the onset of sleep

65. A nurse is assessing a client who has narcolepsy. Which of the following findings should the nurse expect? Select all that apply. a. A lack of rapid eye movement (REM) sleep b. Sudden attacks of sleep c. Hallucinations at the onset of sleep d. Sleep apnea e. The urge to move the legs when trying to sleep

b. Denial

67. A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. When he arrives for his first dialysis treatment, he tells the nurse, "I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again." The nurse should identify that this client is demonstrating which of the following kulber-ross stages of grieving? a. Bargaining b. Denial c. Depression d. Anger

b. The client was lying on the floor next to his bed (nurse should document what they actually see)

68. A nurse is filling out an incident report after finding a client lying on the floor. Which of the following info should the nurse include? a. The client attempted to climb over the side rails and fell b. The client was lying on the floor next to his bed c. The client was restless and trying to get out of the bed all evening d. The presence of a bed alarm could have prevented the client from falling

b. Assess the client (to check if there is any harm to the client)

69. A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first? a. Call the client's provider b. Assess the client c. Notify the nurse manager d. Complete an incident report

b. Determine the client's level of fluency in his primary language (it is important to determine the client's level of fluency in her primary language and the nurse's language to provide teaching the client can understand)

7. A nurse is developing a plan of care for a client who does not speak the same language as the nurse. Which of the following interventions should the nurse include? a. Make sure a family member is present to interpret for the staff. b. Determine the client's level of fluency in his primary language c. Speak directly to the interpreter when teaching the client d. Encourage the client to nod to indicate understanding

c. Use intermittent eye contact

70. A nurse caring for a client is using active listening skills. Which of the following actions should the nurse take? a. Sit side-by-side with the client b. Have a pen and paper handy c. Use intermittent eye contact d. Lean back in the chair

b. Witness the client's signature (verify that the client is consenting to voluntarily and appears to be competent to do so)

71. A nurse is caring for a client who is scheduled for an elective surgical procedure. Which of the following actions should the nurse take regarding informed consent? a. Obtain a client's consent b. Witness the client's signature c. Explain the risks and benefits of the procedure d. Explain the procedure to the client if they do not understand

c. Lock the medication in a room and finish preparing it after returning from the emergency (securing them and returning later to finishing preparing and administering them decreases the risk of medication errors)

72. A nurse is preparing medication for a client when another client has an emergency. Which of the following actions should the nurse take? a. Have another nurse guard the medication preparations until the nurse returns b. Have another nurse finish preparing the medications c. Lock the medication in a room and finish preparing it after returning from the emergency d. Discard the prepared medications and begin again after returning

d. I will wear synthetic clothing and woolen socks when using my oxygen (woolen and synthetic materials can generate static electricity and oxygen is a flammable gas - the client should wear cotton)

73. A nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching? a. I will be able to tell how much oxygen I'm getting by looking at the flowmeter b. I should call my doctor if I find it harder to concentrate c. I will make sure my visitors smoke outside d. I will wear synthetic clothing and woolen socks when using my oxygen

c. Check to see if the suction equipment is working

74. A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client is reporting anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority? a. Request a prescription for a medication to ease the client's anxiety b. Irrigate the NG tube with 100 mL of sterile water c. Check to see if the suction equipment is working d. Remove and reinsert the NG tube

a. Respite care allows the primary caregiver time away from day-to-day care responsibilities

75. A nurse is planning to discharge a client who has quadriplegia to his home. The nurse suggest that the family might need to respite care services. When a family member asks how respite care can help, which of the following responses should the nurse provide? a. Respite care allows the primary caregiver time away from day-to-day care responsibilities b. Respite care provides holistic support and care for a client who is terminally ill c. Respite care helps relieve pain and promote comfort d. Respite care is a continuation of psychological support after a family member dies

d. What have you done in the past to cope with this issue?

76. A nurse is caring for a client whose partner asks to speak with the nurse. The partner relates her concerns about her spouse abusing alcohol and having difficulty maintaining employment. Which of the following responses should the nurse make? a. Could you try contacting a support group b. I'm so sorry to hear about this c. I suggest you talk with a mental health counselor about your concerns d. What have you done in the past to cope with this issue?

c. Shivering (shivering is a systemic response to cold therapy as the body attempts to promote heat production)

77. A nurse is administering a cold therapy application to a client. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? a. Hypotension b. Numbness c. Shivering d. Reduced blood viscosity

a. Auscultating heart sounds c. Changing a dressing

78. A nurse is caring for a client within the intimate zone of the client's personal space. The nurse should perform which of the following activities in this space? Select all that apply. a. Auscultating heart sounds b. Teaching about a medication c. Changing a dressing d. Discussing intake and output e. Talking with the client's partner

b. Removing the abdominal dressing

79. A nurse is working with an AP while caring for a surgical client who is 1 day postoperative. Which task should the nurse take responsibility for completing? a. Measuring vital signs b. Removing the abdominal dressing c. Helping the client into the shower d. Ambulating the client in the hallway

c. Surgeon (the health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client)

8. A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure? a. Nurse b. Anesthesiologist c. Surgeon d. Surgical suite nurse

c. Explore the client's feelings about dietary modifications (this teaching intervention allows the client to express his acceptance of this change and focuses on affective learning)

80. A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. To focus on effective learning with this client, which of the following interventions should the nurse use? a. Ask the client to perform a return demonstration of insulin injection b. Review the action of insulin therapy c. Explore the client's feelings about dietary modifications d. Have the client practice blood-glucose monitoring using a glucometer

d. When asking if the client took his medications this morning

81. A nurse is admitting a client from a long-term care facility. The nurse should use close-ended questions when assessing which of the following factors? a. When determining if the client is eating a well-balanced diet b. When asking the client about his receptiveness to the transfer c. When asking the client how he completes his ADLs d. When asking if the client took his medications this morning

a. Gloves

82. A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following pieces of PPE should the nurse remove first? a. Gloves b. Gown c. Face shield d. Mask

a. Pain

83. A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? a. Pain b. Hearing loss c. The client's culture d. Motor impairment

c. Offering false reassurance

84. A nurse is caring for a client who states, "I have got to get out of this hospital! They have found my address and are coming for my family!" the nurse responds, "don't worry, no one will harm your family." Which of the following types of communication breakdown does this response represent? a. Providing a passive response b. Showing disapproval c. Offering false reassurance d. Offering sympathy

d. Test the pH of gastric aspirate (nurse should verify position of tube, testing pH is acceptable method between x-ray confirmations)

85. A nurse is caring for a client in a long-term facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding? a. Warm the feeding solution to the body temperature b. Place the client in low Fowler's position c. Discard any residual gastric contents d. Test the pH of gastric aspirate

d. Determine if the client uses hearing aids

86. A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse? a. Speak using his usual tone of voice b. Stand directly in front of the client c. Rephrase statements the client does not hear d. Determine if the client uses hearing aids

b. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage

87. A newly licensed nurse is seeking advice from her preceptor about the need to purchase personal professional liability insurance. Which of the following statements should the preceptor make? a. The facility has insurance that will cover malpractice litigation b. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage c. The chances of a malpractice suit are minimal as long as you follow our policies and procedures d. I shouldn't advice you about what is ultimately a personal decision

b. The client's self-report of pain severity

88. A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining intensity of the client's pain? a. Vital sign measurement b. The client's self-report of pain severity c. Visual observation for nonverbal signs of pain d. The nature and invasiveness of the surgical procedure

d. The nurse has already considered alternatives to restraints

89. A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. Which of the following should the nurse include as a criterion for applying restraints? a. The provider must renew a restraint prescription every 8 hr. b. The client must understand the need for restraints c. The restraints should promote the client's safety and prevent injuries d. The nurse has already considered alternatives to restraints

a. Complete a neurological check (appropriate nursing intervention when a client displays sudden confusion)

9. A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, RR 24/min, BP 124/76 mm Hg, and temp 36.8C (98.2 F). which of the following actions should the nurse perform? a. Complete a neurological check b. Administer the prescribed PRN antihypertensive medication c. Increase the fluid intake d. Hold the client's evening dose of digoxin

a. Temporary urinary retention (common for clients to develop after removal)

90. A nurse removes an indwelling urinary catheter that an older client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal? a. Temporary urinary retention b. Urinary frequency for several days c. Blood-tinged urine d. Highly concentrated urine

a. Relief of urinary retention

91. A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include? Select all that apply. a. Relief of urinary retention b. Convenience for the nursing staff or the client's family c. Measurement of residual urine after urination d. Routine acquisition of a urine specimen e. an open perineal wound

b. Oral surgeon

92. A nurse in a clinic is caring for a client who reports pain, crepitus, and a popping sound is his temporomandibular joint. Based on these findings, to which of the following providers should the nurse request a referral for the client? a. Occupational therapist b. Oral surgeon c. Physical therapist d. Otorhinolaryngologist

c. Irrigating a client's abdominal wound e. Suctioning a client's new tracheostomy tube

93. A nurse is adhering to standard precautions while caring for a group of clients. For which of the following tasks should the nurse wear protective eye equipment. Select all that apply. a. Providing hygiene care to a client who is HIV positive b. Emptying a urinary drainage bag for a client who has pneumonia c. Irrigating a client's abdominal wound d. Transporting a cerebrospinal fluid specimen to the lab e. Suctioning a client's new tracheostomy tube

d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours

94. A nurse enters an older adult client's room to insert a saline lock. The client asks the nurse, "Why do I need that? I'm drinking plenty of fluids." Which of the following responses should the nurse provide? a. It is quicker to administer medications intravenously in the hospital b. Clients over the age of 65 must have a saline lock according to facility policy c. We administer all medications intravenously to clients in this unit d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours

c. Tie linen bags securely at the top

95. A nurse on a medical unit is teaching a group of assistive personnel about handling clients' bed linens safely. Which of the following instructions should the nurse include? a. Return any fresh linen not used for a client to the linen supply area b. Use double bagging to remove soiled linen from the client's room c. Tie linen bags securely at the top d. Fill linen bags with as much soiled linen as possible

b. Negligence (negligence is the failure to provide the expected standard of care. The expected standard of care was strict bed rest)

96. A nurse is providing care to a client who is on strict bed rest following surgery. The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. Which of the following types of torts has the nurse committed? a. Battery b. Negligence c. Malpractice d. Assault

b. Protective (clients whose immune system is compromised, such as from chemo, AIDS, or after a stem-cell transplant, require a protective environment)

97. A nurse is caring for a client who has had an allogenic hematopoietic stem-cell transplant. Which of the following infection-control precautions should the nurse use caring for this client? a. Airborne b. Protective c. Contact d. Droplet

d. Bend at the knees when picking up an object

98. A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Which of the following instructions should the nurse include? a. Relax her abdominal muscles when she lifts an object b. Twist at the waist when she moves an object to one side c. Hold an object away from her body as she lifts it d. Bend at the knees when picking up an object

a. Clarification

99. A nurse is caring for a client who is about to have a colonoscopy. The client states, "I am so nervous about what the doctor might find during the test." The nurse asks the client, "Are you feeling anxious about the results of your colonoscopy?" with this question, the nurse is using which of the following communication techniques? a. Clarification b. Summarization c. Confrontation d. Providing information

"Please explain what you mean by the word 'nervous'."

A nurse asks a client how he is feeling. The client states, "I'm feeling a bit nervous today." Which of the following responses should the nurse make?

A. The client faces the direction of movement when sliding an object across the floor (sliding an object across the floor rather than lifting it prevents strain on the lower back muscles and facing the direction prevents from twisting his back)

A nurse is assessing a client at a follow-up clinic for acute low back pain. A goal for this client is to use proper body mechanics at all times. Which of the following findings indicates that the client is meeting this goal? a. The client faces the direction of movement when sliding an object across the floor b. When pushing an object the client moves his front foot backward c. When moving an object to one side, the client pushes his weight on his heels d. The client stands with his feet close together when lifting an object