NUR 240 Exam 1

The nurse is creating a plan of care for a client scheduled for surgery. The nurse would include which activity in the nursing care plan for the client on the day of surgery?

Have the client void immediately before going into surgery.

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse needs to include which piece of information in discussions with the client?

The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

Which notations indicate accurate nursing documentation by the nurse? Select all that apply.

The client slept through the night. Abdominal wound dressing is dry and intact without drainage. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

An older client is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that a family member frequently hits the client if supper is not prepared on time when the family member arrives home from work. The nurse plans to make which most appropriate response?

"As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse?

"Can you share with me what you've been told about your surgery?"

The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking ace-tylsalicylic acid. The nurse determines that the ci-ent needs additional teaching if the client makes which statement?

"I need to continue to take the aspirin until the day of surgery."

A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. The nurse plans to make which most appropriate response to the client?

"I will call the nursing supervisor to seek assistance regarding your request."

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an assistive personnel (AP)?

A client who requires urine specimen collections

The nurse caring for a refugee considers which health care need a priority for this client?

Access to transportation

A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice?

An RN leads two licensed practical nurses (LPNs) and three APs in providing care to a group of 12 clients.

The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action?

Call the nursing supervisor and report the occurrence.

The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse?

Call the nursing supervisor.

A client who has undergone preadmission testing has had blood drawn for serum laboratory stud-ies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result would be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed?

Hemoglobin, 8.0 g/dL (80 mmol/L)

The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving compli-cation?

Increasing restlessness

The nurse manager is discussing with the staff the facility's protocol in the event of a tornado. Which instructions would the nurse manager include in the discussion? Select all that apply.

Move beds away from windows. Close window shades and curtains. Place blankets over clients who are confined to bed.

Which teaching method is most effective when providing health care instructions to members of specific populations?

Teach-back

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an as-sessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. Which statement would the nurse document on the occurrence report?

The client was found lying on the floor

The nurse is completing the admission assessment of a client who is intellectually disabled. Which part of the client encounter may require more time to complete?

The history

A nursing instructor delivers a lecture to nursing students regarding the issue of clients' rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right?

Observing care provided to the client without the client's permission

The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site?

Serous drainage

The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques?

"Use of an incentive spirometer will help prevent pneumonia."

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client would the nurse plan to care for first?

A client with a white blood cell count of 14,000 mm? (14 × 10%/L) and a temperature of 38.4° C

The nurse is assigned to care for four clients. In planning dient rounds, which client would the nurse assess first?

A client with asthma who requested a breathing treatment during the previous shift

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse would assign priority to which client?

A client with chest pain who states that they just ate pizza that was made with a very spicy sauce

The nurse is caring for a client in the emergency department who presents with a complaint of fatigue and shortness of breath. Which physical assessment finding, if noted by the nurse, warrants a need for follow-up?

A reddish-purple mark on the neck

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions would the nurse take? Select all that apply.

Contact the surgeon. Instruct the client to remain quiet. Prepare the client for wound closure. Document the findings and actions taken.

The nurse is giving a bed bath to an assigned client when an assistive personnel (AP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action?

Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other dient.

The nurse planning care for a military veteran needs to prioritize nursing interventions targeted at managing which condition, if present, that commonly occurs in this population?

Post-traumatic stress disorder

The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse needs to call the surgeon to clarify that which medication would be given to the client and not withheld?

Prednisone

Which action by the nurse will best facilitate adherence to the treatment regimen for a client with a chronic illness?

Arranging for home health care

The nurse receives a telephone call from the pos-tanesthesia care unit, stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client?

Assess the patency of the airway.

A client with a gastric ulcer is scheduled for sur-gery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse would take which most appropriate action in the care of this client?

Obtain a telephone consent from a family member, following agency policy.

The nurse has just assisted a client back to bed after a fall. The nurse and primary health care provider (PHCP) have assessed the client and have determined that the client is not injured. After completing the occurrence report, the nurse would implement which action next?

Reassess the client

The nurse has made an error in documentation of the dose administered of an opioid pain medication in the client's record. The nurse draws 1 mg from the vial and another registered nurse (RN) witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the medication administration record (MAR) that 2 mg of hydro-morphone was administered instead of the actual dose administered, which was 1 mg. The nurse would take which actions) to correct the error in the MAR? Select all that apply.

Right-click on the entry and modify it to reflect the correct information. Document the correct information and end with the nurse's signature and title. Obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg. Document in a nurse's note in the client's record detailing the corrected information.

The nurse working in a community outreach program for foster children plans care, knowing that which health conditions are common in this popu-lation? Select all that apply.

Sleep problems Bipolar disorder Aggressive behavior Attention-deficit/hyperactivity disorder (ADHD)

The charge nurse is planning the assignment for the day. Which factors would the nurse remain mindful of when delegating tasks? Select all that apply.

The acuity level of the clients Client needs and workers' needs and abilities

Which is most appropriate when communicating with a transgender person?

Using identified pronouns

The nurse working in a correctional facility is caring for a new prisoner. The client asks about health risks associated with living in a prison. How would the nurse respond?

"Living in a prison can predispose a person to different health conditions."

The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical nurse and three assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse?

A client requiring abdominal wound irrigations and dressing changes every 3 hours

The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse would take which best action?

Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment.

The nurse is volunteering with an outreach program to provide basic health care for homeless people. Which finding, if noted, must be addressed first?

Complaints of pain associated with numbness and tingling in both feet

The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An assistive personnel (AP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the AP?

Confront the AP to encourage verbalization of feelings regarding the change.

The nurse calls the primary health care provider (PHCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due to be administered. Which action would the nurse take?

Contact the nursing supervisor.

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action?

Transport the victim to the operating room for surgery.

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?

Urinary output of 20 ml/hr