NUR 514 - Exam 1
A nurse is evaluating a group of clients who are experiencing pain. Which of the following clients should the nurse identify as experiencing neuropathic pain?
a client who has diabetes mellitus and reports bilateral burning foot pain without signs of injury
A nurse is caring for a client who has severe pain and repeatedly asks for pain medication. The nurse is busy and forgets to assess the client's pain and administer prescribed pain medication. Which of the following can the nurse be charged with?
negligence
A nurse is caring for a client who has a prescription for heat therapy for knee pain. The nurse should apply heat therapy to the clients knee for how long?
20 mins
A nurse is assisting with teaching a group of nurses on processes that can trigger an inflammatory response in the body. The nurse should include that which of the following is an infectious trigger?
bacteria
A nurse is admitting a client who has vancomycin-restistant enterococcus (VRE) of the urine. The nurse should place the client on which of the following precautions.
contact
A nurse is supervising a newly licensed nurse perform hand hygiene. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?
turns off the faucet with a towel
A nurse is providing end-of-life care for a client who is unresponsive and near death. The client's family asks the nurse about managing the client's pain. Which of the following statements should the nurse make to the client's family?
your family member has the right to receive effective pain management
A nurse is reviewing methods created to assist nurses in using evidence practice. Which of the following is a NCSBN model that can assist the nurse with critical thinking and decision making?
Clinical Judgement
A nurse is caring for a client who has a prescription for hydromorphone 1 and 2 mg IM every 4 hours as needed for a pain rating of 4 to 6 on a 0-10 scale. The client has never taken hydromorphone before. Which of the following actions should the nurse plan to take?
administer 1 mg IM
A nurse is wearing gloves while caring for a client. In which of the following situations should the nurse obtain a new pair of gloves?
after changing a dressing on the client and before documenting findings on a computer
A nurse at an urgent care clinic is auscultating the lungs of a client who reports a cough and shortness of breath. Which of the following steps of the nursing process is the nurse using?
assessment
A nurse is planning to admit a client who has respiratory syncytail virus (RSV). Which of the following transmission-based precautions should the nurse plan to implement?
contact precautions
A nurse is caring for a client who states, "I am feeling so much better. My fever is gone, and I have a good appetite." The nurse should identify the client is likely in which of the following stages of infection?
convalescence. This stage is the last stage of infection in which the client returns to a previous or a new, stabilized state of health.
A charge nurse is planning to discuss factors that can influence the clinical decision-making process in client care with a newly licensed nurse. Which of the following factors should the charge nurse include?
available resources, awareness of client status, and support from other staff are all important factors a nurse should include.
A nurse is caring for a client who acquired an infection after touching a faucet that an infected person had touched. Which of the following links in the chain of infection does the faucet represent?
reservoir
A nurse is caring for a group of clients on the pediatric unit. For which of the following clients should the nurse use the FLACC Pain Scale to determine their pain level?
1. a 3 year old toddler who has a fractured femur 2. A 14 year old client who has severe cognitive and developmental delays 3. A 5 year old preschooler who is experiencing pain during a sickle cell crisis
A nurse is reviewing the plan of care for several clients who are receiving treatment for pain. Which of the following actions should the nurse plan to take to evaluate the client's pain control?
1. consider each client's cultural preferences 2. determine the effectiveness of non-pharmacological strategies 3. use a pain scale specific to each clients cognitive abilities
A nurse is discussing transcutaneous electrical nerve stimulation (TENS) treatment with a client who has chronic lower back pain. Which of the following statements should the nurse include?
1. you can be taught how to use TENS therapy at home 2. The TENS therapy delivers low-voltage electrical impulses to the skim over the painful areas 3. We will adjust the intensity, pulse rate, and duration of the electrical pulses during your therapy
A nurse is reviewing information for several clients on the unit. The nurse should recognize that which of the following clients is at greatest risk for respiratory depression?
A client who had surgery 3 hours ago and is receiving IV hydromorphone PRN
A nurse is assisting with teaching a newly licensed nurse about laboratory tests that can indicate generalized inflammation. The nurse should include which of the following laboratory tests?
C-reactive protein. It is a nonspecific marker that can increase when inflammation is present.
A nurse in a clinic is caring for a client who reports generalized aches and fever for the past 12 hrs. The nurse suspects the client has acquired an infection. Which of the following stages of infection is the client likely experiencing?
Prodromal stage. Is the second stage of infection. In this stage, the client begins having vague, nonspecific manifestations, such as fever, chills, headache, and malaise, as the infectious agent replicates.
A nurse is caring for a client who is in an acute care facility. The nurse should recognize that the clients care requires clinical reasoning when it is complicated by which of the following factors?
When it is complicated by complex clinical situations and ongoing client and family concerns, that is when the nurse should use clinical reasoning
A nurse is assisting in providing an in-service about infectious agents to a group of nurses. The nurse should include in the teaching that tuberculosis is transmitted by which of the following modes of transmission?
airborne
A nurse is assisting with teaching a newly licensed nurse about infection control. The nurse should include in the the teaching that which of the following types of precautions requires the use of an N95 mask?
airborne
A nurse is assisting with teaching a newly licensed nurse about hand hygiene for surgical asepsis. Which of the following instructions should the nurse include?
apply chlorhexidine and ethanol to the hands.
A nurse is reviewing the concept of critical thinking with a newly licensed nurse. Which of the following statements should the nurse make?
critical thinking is the foundation for clinical decision making.
A nurse is caring for a client who has been wheezing. The nurse asks an assistive personnel to use a stethoscope and listen to the client's lung sounds to determine if their wheezing has improved. This is an example of the following concepts?
delegation of the wrong task
A nurse is caring for a client who has influenza. The client asks how they acquired the infectious agent. The nurse should inform the client that influenza is transmitted by which of the following modes?
droplet
A nurse is assisting with teaching a newly licensed nurse about infectious agents. The nurse should include in the teaching that pertussis is transmitted by which of the following modes of transmission?
droplet transmission
A nurse asks a client to rate their current level of pain using a scale of 0-10 after administering pain medication 30 min ago. Which of the following steps of the nursing process is the nurse performing?
evaluation
a nurse is assisting with teaching a newly licenses nurse about removing personal protective equipment (PPE). Which of the following items should the nurse instruct to remove first?
gloves
A nurse is assisting with teaching about personal protective equipment with a newly licensed nurse. Which of the following instructions should the nurse include?
gloves should be removed from the inside out
A charge nurse is preparing to discuss critical thinking skills with a group of newly licensed nurses. Which of the following skills should the nurse plan to include in the discussion?
inspection, inference, creativity and inductive reasoning
A nurse is caring for a client who is postoperative following abdominal surgery and has a morphine PCA pump. Which of the following medications should the nurse ensure is available in case the client develops respiratory depression?
naloxone
A nurse is setting up a sterile field to perform a dressing change on a client. Which of the following actions should the nurse take?
open the first flap on the sterile package away from their body
A nurse is caring for a client who is on contact precautions. Which of the following actions should the nurse take?
place the client in a private room
A nurse is developing a goal for a client to ambulate with assistance at least once by the end of the shift. The nurse should identify that this is an example of which of the following steps of the nursing process?
planning
A nurse is assisting with teaching a newly licensed nurse about surgical asepsis. Which of the following statements should the nurse make?
remove nail polish on your fingernails if it is chipped
A nurse is assisting with teaching a newly licensed nurse about needlestick injuries. Which of the following instructions should the nurse include?
report needlestick injuries to the nursing supervisor
A nurse is performing hand hygiene after caring for a client who has Clostridium difficile. Which of the following hand hygiene methods should the nurse use?
soap and water
A nurse is caring for a client who has acquired an infection with a visitor. The client is an example of which of the following links in the chain of infection?
susceptible host. This is the client who acquired the infection. The susceptible host becomes a reservoir for the infectious agent.
A nurse is performing a throat culture on a client. Which of the following actions should the nurse take?
swab the back of the client's pharyngeal wall
A nurse is assisting with teaching a newly licensed nurse about airborne infection isolation rooms (AIIR). Which of the following information should the nurse include?
the door to the AIIR should remain closed
A nurse is assisting with implementing an infection control bundle for clients at risk for catheter-associated urinary tract infections (CAUTIs). Which of the following interventions should the nurse include in the bundle?
try to use alternatives before inserting indwelling urinary catheters
In what order should an RN perform the steps of the nursing process?
Assessment, Analysis, Planning , Implementation, and Evaluation