Nursing Semester 1 Final Review (Flexi)

A client made a formal request to review their medical records. With review, the client believes there are errors within the medical record. What is the most appropriate nursing response?

"According to HIPAA legislation, you have a right to request changes to inaccurate information."

An older adult client tells the nurse, "I don't bother exercising because I get too tired very quickly." What is the appropriate nursing response?

"Alternate periods of activity with periods of rest."

A patient is reporting burning on urination. Which question should the nurse ask to best obtain information about the patient's dysuria?

"Can you tell me about the problems you have been having with urination?"

A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate?

"Clipboards with client data should not leave the unit."

A middle-age client is reporting acute joint pain to a nurse who is assessing the client's pain in a clinic. Which question related to pain assessment should the nurse ask the client?

"Does your pain level change after taking medications?"

The nurse is teaching a nursing student about caring for a client with dentures. Which education will the nurse provide?

"Hold dentures over a plastic basin or towel when cleaning them."

A patient is being admitted to the hospital and the nurse is performing a complete assessment. Which is the most therapeutic question the nurse can ask about the quality of the patient's sleep?

"How would you describe your sleep?"

Which patient statement indicates that the patient is experiencing bruxism?

"I am told by my wife that I make a lot of noise grinding my teeth when I sleep."

The nurse collects objective data when a hospitalized patient states:

"I ate half my lunch."

The nurse is counseling a woman who is caring for her 83-year-old father. The father has had mental changes and is becoming more confused. The father lives with the daughter in her home. The nurse knows the daughter understands the father's care needs when she states which of the following?

"I can send dad to the adult daycare; that way I can work and care for him at night."

A nurse finds that a client has infiltration around the IV line that needs to be removed. What explanation should the nurse give to reduce the client's anxiety?

"I know that you are anxious, but removal will be painless and the IV location needs to be changed."

Which patient statements indicate that further teaching by the nurse is necessary regarding how to ensure protection from food contamination? Check all that apply

"I love juicy rare hamburgers with onion and tomato." & I should stuff a turkey an hour before putting it in the oven."

A mother tells the nurse she is concerned because her 8 month old infant sleeps all day and night and is only awake about 2-3 hours per day. What is the nurse's best response?

"I recommend that you notify the child's pediatrician."

A nurse is caring for an older adult client who has just died in a hospice unit. The child of the client arrives and asks, "Can I please stay and sit at the bedside? I really wanted to be here so they did not die alone." Which statement made by the nurse best demonstrates the use of empathy?

"I will close the door so you can spend some quiet time at the bedside."

The nurse is teaching a client who had a below-the-knee amputation about a temporary prosthetic limb. Which client statement demonstrates that teaching has been effective?

"I will loosen the belt when I go to sleep."

The nurse is preparing a female client for surgery. The client tells the nurse that she is a Jehovah's Witness and is afraid that the staff will administer blood to her during the procedure while she is under anesthesia. Which is the nurse's best response to the client?

"I will place a notice on your chart and report to the surgical team that you will not allow blood or blood products to be given."

The nurse has arranged to start an IV line for a client with pancreatitis. The nurse notes that the client appears anxious about the procedure. What is the most appropriate response by the nurse to decrease the client's anxiety?

"I will start an IV that will add fluids directly to the blood stream."

A patient is extremely upset and mentions something about a work-related issue that the nurse cannot understand. Which is the nurse's best response?

"I'm not quite sure I heard what you were saying about your work."

The nurse identifies that the patient statement that provides subjective data is:

"I'm not sure that I am going to be able to manage at home by myself."

A nurse is teaching a client about the prescribed potassium replacement therapy which the client will continue at home. After teaching the client about this therapy, the nurse determines that additional teaching is warranted when the client makes which statement?

"If I have trouble swallowing the drug, I can crush it."

A nurse is caring for a client with depression. The nurse finds that the client is withdrawn and does not communicate with others. What is the most appropriate response by the nurse?

"Is that a new shirt you're wearing?"

A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response?

"It allows for removal of blood and drainage from the surgical wound."

The nurse is teaching a client who will undergo abdominal surgery to repair a hernia about deep breathing. When the client asks, "Why am I practicing breathing when I'm having hernia surgery", what is the appropriate nursing response?

"It decreases the postoperative risk for respiratory complications."

A nurse instructs a patient to inhale deeply and hold each breath for a second when using a hand-held nebulizer. The patient asks, "Why do I have to hold my breath?" Which information should the nurse include in the response to the patient's question?

"It disperses the medication."

A client with diabetes mellitus must monitor carbohydrate intake. Which client statement requires nursing intervention?

"My favorite drink is coffee with sugar."

The nurse understands that subjective data has been obtained when the patient states:

"My pain feels like a 5 on a scale of 1 to 5."

While caring for a client with chronic pain, the nurse talks with a family member. Which family member statement does the nurse identify as consistent with caregiver role strain?

"Sometimes it seems like I can never get a moment to myself."

The nurse is teaching a client about wound care at home following a Cesarean section to deliver her baby. Which client statement requires further nursing teaching?

"Steri-Strips will hold my wound together until it heals."

Which teaching will the nurse include when educating a client about stump socks?

"Stump socks can be made of cotton or wool."

A client being discharged from the hospital asks the nurse, "When I go visit my family out of state, should I take my living will with me, or do I need a new one for that state?" What is the most appropriate response made by the nurse?

"Take it with you. It is recognized universally in the United States."

A client is discussing vitamin and mineral intake with the nurse. Which client statement requires nursing intervention?

"Taking megadoses of vitamins will help me increase muscle mass quickly."

A nurse pays a house visit to a client who is on parenteral nutrition (PN). The client expresses that he misses enjoying food with his family. What is the most appropriate response by the nurse?

"Tell me more about how it feels to eat with your family."

A nurse visits a female victim of sexual assault for the fourth visit. The client expresses that she is unable to cope with the trauma. Even though the assault occurred quite some time ago, she feels as if it just happened yesterday. What is the most appropriate response by the nurse?

"Tell me more about the aspects that make you feel as if it happened yesterday."

The client is concerned about "catching the flu." Which statement by the nurse is most appropriate?

"The best way to prevent the spread of illness is by washing your hands."

Which are appropriately worded goals for a patient who is at risk for falling? Select all that apply.

"The patient will be able to walk from a bed to a chair safely while hospitalized." & "The patient will be free from trauma."

A nurse is performing an admitting interview. Which patient statement about pain should cause the most concern for the nurse?

"They say my pain may get worse, and I can't stand it now."

The nurse is teaching a client about healing of a minor surgical wound by first-intention. What teaching will the nurse include?

"Very little scar tissue will form."

A staff nurse reports a medication error due to failure to administer a medication at the scheduled time. What is the charge nurse's best response?

"We'll conduct a root cause analysis."

. A nurse is collecting data for an admission nursing history. Which question by the nurse is best to open the discussion?

"What brought you to the hospital?"

The student nurse is discussing the benefits of electronic charting with a precepting nurse who is frustrated with computerized documentation. Which statement by the student requires intervention from the nursing instructor?

"You can make extra money with overtime pay with end-of-shift charting."

A nurse is assessing vital signs on a pregnant client during a routine prenatal visit. The client states, "I know labor will be so painful, it sounds awful. I am sure I will not be able to stand the pain; I really dread going into labor." What is the best response from the nurse?

"You're worried about how you will tolerate the pain associated with labor."

A 17-year-old client who lives with her parents wishes to have a breast reduction. Which information will the nurse provide to the client?

"Your parent or legal guardian must sign the consent form."

A nurse is caring for a postoperative patient over an 8-hour period. The patient vomits 300 mL of greenish-yellow fluid. The patient's intravenous fluids are infusing at 125 mL per hour. The patient received 2 intermittent infusions of antibiotics each in 50 mL of solution and they were infused at a different site than the IV fluid infusion. The patient was given 8 ounces of ice chips which were retained. The patient urinated twice—250 mL and 400 mL. Which is the patient's total fluid intake at the end of the 8-hour period?

1,220 mL

A nurse identifies the presence of smoke exiting the door to the dirty utility room. Place the nurse's actions in order of priority using the RACE model. 1. Pull the fire alarm. 2. Close unit doors and windows. 3. Shut the door to the utility room. 4. Provide emotional support to agitated patients.

1,3,2,4

A nurse obtains the blood pressure of several adults. Which blood pressure result should cause the most concern?

140/90 mmHg

The nurse is calculating the maximum heart rate for a 60-year-old client. Which accurately reflects the client's maximum heart rate?

160 beats per minute

The nurse is documenting morning care for a client with diabetes. Which documentation is most appropriate for this client?

1600: Consumed 80%of breakfast. Reports pain level of 3 on scale of 1-10.

A patient is admitted with a tentative diagnosis of myasthenia gravis. The physician orders edrophonium chloride (Tensilon) 2 mg to be administered intravenously. After no reaction the physician orders8 mg to be administered intravenously. The expected response is an improvement in muscleweakness confi rming the diagnosis of myasthenia gravis. However, within 30 seconds after administration of the 8 mg of Tensilon, the patient experiences a cholinergic reaction with increased muscle weakness, bradycardia, diaphoresis, and hypotension. The physician orders atropine sulfate 1 mg to be administered intravenously stat. The vial of atropine sulfate indicates 0.5 mg/mL. Calculate how many mLs of atropine sulfate the nurse should administer intravenously.

2 mL

Edrophonium IV is administered to a patient suspected of having myasthenia gravis. Within 30 seconds after administration of the edrophonium, the patient experiences a cholinergic reaction with increased muscle weakness, bradycardia, diaphoresis, and hypotension. The primary health-care provider prescribes atropine sulfate 1 mg IV STAT. The vial of atropine sulfate indicates 0.5 mg/mL. Calculate how many milliliters of atropine sulfate the nurse should administer.

2 mL

A nurse administers a back rub to a patient after first providing for privacy and maintaining standard precautions. Place the following steps in the order in which they should be implemented. 1. Apply warmed lotion to your hands. 2. Position the patient in the side-lying position. 3. Assess the skin for color, turgor, and skin breakdown. 4. Arrange the gown and top linens so that the patient's back is exposed. 5. Use a variety of strokes to massage the muscles of the back and sacral area.

2,4,3,1,5

The nurse is caring for four clients. Which does the nurse anticipate may have a latex sensitivity?

21-year old who cannot eat bananas

The nursing instructor is discussing with the nursing class about fluid and electrolyte balance. What would the instructor tell the students that the average daily fluid intake for an adult is?

2500 mL

After assessing a patient's learning needs, abilities, and motivation and identifying patient goals, the nurse must formulate a teaching plan. Place the following steps in the order in which they should be implemented. 1. Choose teaching strategies to be employed. 2. Evaluate the effectiveness of the teaching plan. 3. Identify the information that the learner must learn. 4. Organize the information in the sequence that information is to be presented. 5. Develop instructional materials that will reinforce and supplement information provided in the class.

3,4,1,5,2

A nurse is caring for a critically ill patient with a urinary retention catheter. Which hourly urine output should first alert the nurse that the primary health-care provider should be notified?

30 mL

The nurse is caring for four clients. Which client presents the most susceptibility for infection?

46-year old with a foley catheter following anesthesia

The nurse is assessing a patient for risk factors of chronic fatigue syndrome. Which factors should the nurse identify as placing the patient at risk for chronic fatigue syndrome? (Select all that apply.)

5 episodes tonsillitis/past year & Feeling tired upon awakening & Tenderness under the jaw & Swollen, painful knees

A health care provider orders 1000 mL normal saline to be infused over a period of 6 hours. If the drop factor is 20 drops/mL, the nurse would set the IV flow rate at ____. (Round off answer to whole number.)

56 drops/min

he physician asks the nurse to witness an informed consent. The nurse understands that a patient who is unable to give an informed consent for surgery is a:

65-year-old man who has received a narcotic for pain

A nurse suspects that an older adult's insomnia may be partially attributable to excessive daytime napping. The nurse has taught the client that the client may not need as much sleep as the client believes. The nurse should know that older adults typically require how much sleep in any given 24-hour period?

7 to 9 hours

The nurse is monitoring the vital signs of a group of patients. When reviewing these results, the nurse must remember that body temperature usually is at its highest at:

8 PM-10 PM

When evaluating the vital signs of a group of patients the nurse takes into consideration the circadian rhythm of body temperature. At which time of day is body temperature usually at its highest?

8 p.m. to 10 p.m.

The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client's laboratory reports first for an electrolyte imbalance?

A 52-year-old with diarrhea

A nurse is aware of the varied therapeutic applications for hot and cold application. Which clients may benefit the most from the application of heat?

A client who is experiencing back spasms.

The nurse is caring for a client with frequent dizziness. The nurse is evaluating the client for postural hypotension. Which of the following symptoms would indicate a potential diagnosis?

A drop in systolic blood pressure (15 mm Hg) upon rising

The nurse is caring for a client prescribed a low-sodium diet. Which food, identified as a client favorite, will the nurse discourage?

A hot dog with catsup

A nurse is delegating some aspects of client hygiene to an unlicensed care provider and is ensuring the care provider has adequate knowledge to safely perform shaving. With which client would the use of a razor be contraindicated?

A man who has a history of stroke and who takes oral anticoagulants

In which of the following answers is the hospital in compliance with the Consolidated Omnibus Budget Reconciliation Act and Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA)?

A patient with chest pain is triaged directly to a room for evaluation and registration information is obtained after the patient is stabilized.

A student nurse is studying clinical judgment theories and is working with Tanner's Model of Clinical Judgment. How can the student nurse best generalize this model?

A reflective process where the nurse notices, interprets, responds, and reflects in action.

During a nursing shift, which events warrant completion of an incident report? (Select all that apply.)

A visitor slipped and fell in the hallway, but was not injured. & An intravenous antibiotic was administered 2 hours late because the IV site infiltrated. & A client falls while being transferred from the bed to the chair.

What is one process by which dissolved chemicals move from one area of the body to another?

Active transport

A patient who had a total abdominal hysterectomy two days ago reports abdominal pain at level 5 on a 0-to-10 pain scale. After assessing the pain further, which should the nurse do first ?

Administer the prescribed analgesic

A nurse educator designed various educational programs that employ role-playing as a teaching strategy. Which group of people should the nurse anticipate will benefit the most from role-playing?

Adolescents learning to abstain from recreational drug use

A nurse is caring for an older adult client at risk of injury due to confusion. The client has a stable gait. Which method of restraining should the nurse use?

Alarm-activating bracelet

A nurse is teaching an older adult how to perform a dressing change. Which nursing action is most important to address a developmental stress of older adults?

Allow more time for the patient to process information.

The nurse is reviewing lab work on a newly admitted client. Which of the following diagnostic studies confirm the nursing diagnosis of Deficient Fluid Volume? Select all that apply.

An elevated hematocrit level & Electrolyte imbalance

A sentinel event refers to which situation?

An event that signals the need for immediate investigation and response.

A nurse is monitoring a client who is receiving potassium IV in response to long-term diuretic use. Which signs or symptoms should the nurse now prioritize on the ongoing assessment of this client? Select all that apply.

Anxiety & Cardiac arrhythmias & Paresthesias

A nurse strains a back muscle when moving a patient up in bed. Which can the nurse do at home that utilizes the gate-control theory of pain relief to minimize the discomfort?

Apply a cold compress to the site for 20 minutes

A patient is experiencing constipation. Which independent nursing actions facilitate defecation of a hard stool? Select all that apply.

Applying a lubricant to the anus & Placing a warm wet washcloth against the perianal area & Encouraging the patient to rock forward and back while defecating

A patient is the primary caregiver for a disabled family member at home, and has now been unexpectedly hospitalized for surgery. What action can the nurse take to enhance the coping ability of the patient?

Ask if there is another family member who can help at home while the patient is in the hospital.

The nurse is caring for a terminally ill client who is from Mexico. Which nursing intervention regarding spiritual care is appropriate?

Ask the client if a spiritual leader is desired.

The client is self-monitoring blood pressure at home and reports that every reading is 150/90 mm Hg. What is the priority nursing intervention?

Ask the client to demonstrate self-blood pressure assessment.

The nurse manager hears a nurse and a UAP talking about a female client who reports pain of 8 out of 10 on a 1-10 after a Caesarean birth to deliver twins. The nurse states, "I don't believe this client has any pain at all. I'm sure she is just drug seeking." What is the appropriate nurse manager action?

Ask the nurse to speak privately for a moment, and educate about bias in pain treatment.

The nurse is caring for an older Chinese adult male who is grimacing and appears restless after abdominal surgery. What is the nurse's best action?

Ask the patient about pain and assess vital signs.

The nurse is faced with an ethical issue. When assessing the ethical issue, which action should the nurse perform first?

Ask, "What is the issue?"

A client is administered an anxiolytic. Which nursing action demonstrates the nurse evaluating the client?

Asking if the client feels less anxious 30 minutes after administering the medicine

An anxious patient repeatedly uses the call bell to get the nurse to come to the room. Finally the nurse says to the patient, "If you keep ringing, there will come a time I won't answer your bell." This is an example of:

Assault

A nurse is designing a teaching-learning program for a patient who is to be discharged from the hospital. After developing a nurse-patient relationship, which should the nurse do next?

Assess the patient's current understanding of the content to be taught.

The nurse is caring for a client who refuses most foods on the dietary tray. Which nursing intervention is appropriate?

Assess when client generally eats meals.

The nurse is fitting a client for axillary crutches. Which action will the nurse perform first?

Assist the client who can support his or her own body weight to a standing position at the bedside.

36. Which should the nurse do to best prevent a patient from falling?

Assist the patient with ambulation

A nurse is helping a patient who is experiencing mild pain to get ready for bed. Which nursing action is most effective to help limit pain?

Assisting with relaxing imagery

A nurse is interviewing an American Indian client who has come to the clinic for a follow- up visit. The nurse notices the client does not make eye contact and speaks while looking down. How should the nurse respond?

Assume a position at eye level with the client and continue with the interview.

A nurse is preparing to administer a tablet to a patient. When should the nurse remove the medication from its unit dose package?

At the patient's bedside

A patient has abdominal surgery. Which should the nurse do to best assess for a sign of postoperative ileus in this patient after surgery?

Auscultate for bowel sounds

A nurse is caring for a client who has started phototherapy for seasonal affective disorder. Which instruction should the nurse give the client to prevent the recurrence of symptoms?

Avoid abrupt discontinuation of the therapy.

When attempting to administer a 10:00 PM sleeping medication, the nurse assesses that the patient appears to be asleep. What should the nurse do?

Awaken the patient to administer the drug

A nurse compares the advantages and disadvantages of a central venous catheter inserted into a peripheral vein and a central venous catheter inserted into a subclavian vein. Which of the following reasons does the nurse conclude is the reason why a peripheral catheter is more desirable?

Because it will not cause a tension pneumothorax

At which time does a nurse medicate a patient for pain for it to be considered preemptive analgesia?

Before doing a dressing change that has been painful in the past

The nurse is providing nutritional instruction to the client diagnosed with hypovolemia. Which would the nurse emphasize as something to avoid?

Beverages with alcohol or caffeine

The emergency department (ED) nurse is caring for a client with a possible acid-base imbalance. The physician has ordered an arterial blood gas (ABG). What is one of the most important indications of an acid-base imbalance that is shown in an ABG?

Bicarbonate

Which technique should the nurse use to assess the pupillary light reflex on a client?

Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction.

A nurse is preparing to help a client with a skin infection have a tub bath. In which way can the nurse ensure the client's safety?

Check that the bathroom has a non-skid floor.

The nurse is preparing to provide hygiene for a client who has a leg cast and activity restrictions. Which is the priority nursing intervention that will be performed to prepare for hygiene care?

Check the nursing care plan for hygiene directives.

During the admission phase, the nurse is required to assess the client and collect information for the data base. The nurse can also delegate some part of the work to other ancillary staff. Which of the following can the nurse delegate to the other staff?

Client's physical assessment

An elderly client has been admitted to a health care facility with a fractured arm and the nurse has to help the client change from a hospital gown into the client's clothing. How should the nurse ensure the client's comfort?

Clothes should have front zippers.

The nurse is interviewing a newly admitted patient. Which patient statement indicates the onset of a fever? "I feel:

Cold

The nurse understands that the primary goal of the assessment phase of the Nursing Process is to:

Collect and cluster data

A client with medically complicated pregnancy has expressed frustration about the disparities in advice and treatment that the client has received at various sites over the past several months. How can the nurse best ensure that there is continuity in the care that the client receives?

Communicate clearly and frequently with other care providers.

Upon shift report, the nurse states the following laboratory values: pH, 7.44; PCO2, 30 mm Hg; and HCO3, 21 mEq/L for a client with noted acid-base disturbances. Which acid- base imbalance do both nurses agree is the client's current state?

Compensated respiratory alkalosis

The nurse receives report that a client's pH level is 7.4. Which nursing action would be most appropriate?

Complete a head-to-toe assessment.

Which is the first action the home-care nurse should employ to prevent falls by an older adult living at home?

Conduct a comprehensive risk assessment

A nurse is caring for a client who is scheduled to undergo a breast biopsy. Which major task does the nurse perform immediately during the preoperative period?

Conduct a nursing assessment.

A nurse educator is teaching a group of newly hired nursing assistants. Which hospitalized patient should they be taught is at the greatest risk for injury?

Confused middle-aged man

A client who has started using contact lenses visits a health care facility with an eye infection. The nurse observes that the client also has an eye abrasion. What could be the possible reason for the eye infection?

Contact lenses were not cleaned.

A patient had a colonoscopy with several polyps excised for biopsies. The nurse teaches the patient routine post-procedure expectations. Which physical responses should the nurse instruct the patient to report to the primary health-care provider? Select all that apply.

Continuous abdominal cramping & Extensive abdominal bloating

A resident brings several electronic devices to a nursing home. One of the devices has a two-pronged plug. Which rationale should the nurse provide when explaining why an electrical device must have a three-pronged plug?

Controls stray electrical currents

A nurse is auscultating the lungs of a client during a physical exam. The nurse notes low-pitched, soft breath sounds over the posterior middle lobes with intermittent, high- pitched, popping sounds in the posterior lower lobes, primarily during inspiration. What is the nurse's correct interpretation of these findings?

Crackles are audible in the posterior bases bilaterally and they are abnormal.

The nurse is assessing the coping patterns of a newly admitted patient. What will the nurse include in this assessment? (Select all that apply.)

Current stressors as perceived by the patient & Use of drugs or alcohol & Recent weight changes

A nurse is counseling a patient with the diagnosis of osteoporosis. In addition to calcium, which vitamin supplement should the nurse anticipate that the primary health-care provider will prescribe for this patient?

D

The nurse is documenting assessment findings of a client diagnosed with anasarca. Which nursing documentation best shows improvement in disease progression?

Decreased abdominal girth

The nurse understands that the appropriateness of a Nursing Diagnosis is supported by its:

Defining characteristics

Which is the appropriate patient outcome for an adult who has disturbed sleep because of nocturia?

Demonstrate a reduction in nighttime bathroom visits.

After evaluating the meal tray of a Jewish client, the nurse notices the client ate none of the meal. Which intervention should the nurse implement first?

Determine why the client is not eating any of the meal

A nurse is caring for a client with neck pain. The nurse is explaining neck pain and some basic methods for pain management to the client. Which pain-management facts should the nurse mention to the client and the client's family?

Discuss pain-control methods with the physician.

A nurse instructs a patient to close the eyes after the administration of eye drops. Which rationale for this instruction should the nurse explain to the patient?

Disperses the medication over the eyeballs

A nurse is assessing a client receiving a continuous IV infusion. Which assessment findings should the nurse prioritize? Select all that apply.

Distended neck veins & Rapid breathing

A patient tells the nurse that he experiences daytime fatigue even after 7-8 hours of sleep each night. What is the best assessment question for the nurse to ask?

Do you also have any recent lifestyle or behavior changes?

A nurse is caring for a client who has had antiembolism stockings applied to avoid thrombus formation. Which measure can prevent thrombi?

Drink plenty of fluids unless contraindicated.

A client was admitted to the unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and family? Select all that apply.

Drink water as an inexpensive way to meet fluid needs. & Drink at least eight glasses of fluid each day. & Respond to thirst.

An adult patient consistently tries to pull out a urinary retention catheter. As a last resort to maintain integrity of the catheter and patient safety, the nurse obtains an order for a restraint. Which types of restraints are most appropriate in this situation? Select all that apply.

Elbow restraint & Mitt restraint & Wrist restraint

An assessment of which of the following is most important when a nurse is caring for an adult patient experiencing vomiting?

Electrolyte values

The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. What is the nurse's first action?

Elevate and support the stump.

Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration?

Elevated hematocrit level

A nurse is caring for a terminally ill client whose death is imminent. The nurse has developed a close relationship with the family. Which intervention is most appropriate?

Encourage family discussions of feelings.

A nurse has noticed that an older adult's hearing aid frequently produces a shrill, high- pitched noise. What possible solution should the nurse suggest to this problem with feedback?

Encourage the client to make sure the hearing aid is fully inserted in the ear canal.

An elderly female client has been admitted to the hospital with a suspected bowel obstruction. The nurse is reviewing the admitting physician's orders and reads the order "NPO". Based on this order, what action should the nurse take?

Ensure that the client does not eat or drink anything

A nurse is documenting the plan of care for a client with AIDS. Which of the following is most important when documenting the plan of care?

Ensure that the client's medical record and nursing interventions are written.

When maintaining medical records for a client, the nurse knows that a medical record also serves as a legal document of evidence. What should the nurse do to ensure legal defensible charting?

Ensure that the client's name appears on all pages.

An elderly woman's poor nutritional status, low body mass index, and impaired mobility have put her at a high risk for developing pressure ulcers. This client's nurse should prioritize which action in order to prevent her development of pressure ulcers?

Ensure that the client's position is changed frequently and regularly.

Which nursing action is common to all instruments when taking a temperature?

Ensure that the instrument is clean

A primary health-care provider prescribes a medicated powder to be applied to a patient's lower leg. Which is most essential for the nurse to do when applying the medicated powder?

Ensure that the skin surface is dry.

A male patient is admitted to ambulatory care for a bilateral herniorrhaphy. A nurse on the unit interviews the patient, obtains the patient's vital signs, and reviews the primary health-care provider's orders. Which should the nurse do first ? Please read below, PATIENT'S CLINICAL RECORD Primary Health-Care Provider's OrdersNothing by mouthIVF: 0.9% sodium chloride at 125 mL/hour Midazolam 5 mg, IM on call to preoperative suite Vital Signs Temperature: 99.2°F, orally Pulse: 96 beats per minute Respirations: 22 breaths per minute Blood pressure: 124/82 mm Hg Patient Interview Patient states "I am a little nervous because I have never had surgery before." During preoperative testing patient indicated an allergy to oxycodone/acetaminophen but forgot to include allergies to latex and peanuts.

Ensure the patient's allergy band includes the patient's identified allergies. ✓

An occupational nurse is facilitating a weight reduction group discussion. Which should the nurse explain is the most common contributing factor of obesity?

Excessive caloric intake

A nurse is caring for a patient who is experiencing pain. For which common psychological response to pain should the nurse assess the patient.

Experiencing fear related to loss of independence

A nurse is caring for a postoperative Asian American client after knee arthroplasty. The nurse plans to help the client ambulate, but is aware that the client may feel threatened due to physical closeness. What would be the most appropriate nursing action?

Explain the purpose and need for assistance during ambulation.

A nurse is teaching a patient colostomy care in relation to the affective domain. Which teaching method is most effective for this situation?

Exploring how the patient feels about having a colostomy

A nurse is assessing a mentally challenged adult client who is in pain after a fall from a staircase. Which scale should the nurse use to assess the client's pain?

FACES scale

Which are most important for a nurse to consider when a patient reports the presence of pain? Select all that apply.

Fatigue increases the intensity of pain experienced by the patient. & The person feeling the pain is the authority on the pain

Which concept associated with sleep should the nurse consider to plan nursing care for a hospitalized patient?

Fear can contribute to the need to stay awake.

A nurse is preparing a sterile field in order to perform a dressing change for a client. Which step should the nurse take when preparing to pour a sterile solution into the dressing tray?

First pour and discard a small amount of the solution.

Several patients are taking supplemental calcium daily. The nurse teaches them to maintain their fluid intake at a minimum of 2,500 mL. The nurse explains that this intervention is designed to prevent which complication?

Formation of kidney stones

40. Which is the best choice for an appetizer when teaching a patient about a 2-g sodium diet?

Fresh vegetable sticks

. A nurse is caring for a client with a fracture in his hand. How should the nurse assist the client to change his clothes?

Gather the garment and work it up and over the body.

A nurse is teaching a patient recently diagnosed with diabetes mellitus the step-by-step procedure of administering an insulin injection by using an orange. However, after two sessions of practice the patient is still reluctant to self-administer the insulin. Which should the nurse do?

Give the patient an opportunity to explore concerns about the injection.

Health care professionals are required to follow certain principles to ensure that nosocomial infections do not occur in the health care facility. What contributes to infections in health care settings?

Health professionals donning artificial nails

The nurse should be aware of legal principles associated with nursing practice. Therefore, the nurse should understand that related to the doctrine of respondeat superior

Health-care facilities are responsible for the negligent actions of the nurses whom they employ

A nurse is monitoring a client who has been experiencing severe vomiting. Which signs and symptoms will the nurse prioritize when alerting the health care provider of possible complication occurring? Select all that apply.

Hypotension & Cold, clammy skin & Anxiety

Which nurse to provider interaction correctly utilizes the SBAR format for improved communication?

I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood sugar is 250, and I wondered if you would like to adjust the sliding scale insulin."

A nurse is documenting a patient's I&O. Which should be recorded at approximately half its volume?

Ice chips given by mouth

The nurse performs an assessment of a newly admitted patient. The nurse understands that this admission assessment is conducted primarily to:

Identify important data

The nurse is caring for a group of hospitalized patients. What should the nurse do first to prevent patient infections?

Identify patients at risk

Which is the priority nursing intervention to prevent patient problems associated with latex allergies?

Identify persons at risk

The nurse is developing a care plan for a patient with ineffective coping skills. Which intervention would be an example of a problem-focused coping strategy?

Identifying a confidant to share feelings

Which nursing action reflects an activity associated with the diagnosis step of the Nursing Process?

Identifying the patient's potential risks

The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified?

In dehydration, only extracellular is depleted.

When planning to evaluate a patient's satisfaction with a teaching activity, what is the most appropriate strategy?

Include a survey instrument.

A patient exhibits an increasing blood pressure and 2-lb weight gain over 2 days. Which additional clinical manifestation can be clustered with these data?

Increase in pulse volume

The school nurse is assessing coping skills of high school students who attend an alternative school for students at high risk to not graduate. What is the priority concern that the nurse has for this student population?

Increased risk for suicide

A stable client is brought to the emergency department after ingesting too much prescribed medication. What is the highest priority nursing intervention?

Induce vomiting.

A client had a total knee replacement performed 3 days ago and is now preparing for discharge home. What discharge teaching should the nurse provide to this client? (Select all that apply.)

Information about follow-up appointments that may be required & Potential side effects of prescribed medications & Guidelines for safely resuming normal activities & Information about the signs and symptoms of infection ✓

A nurse caring for a client who is being treated by three physicians uses the source- oriented format for documentation. What are the benefits of using this format of documentation?

Information is documented in separate forms by each health care personnel.

A nurse must apply a hospital gown that does not have snaps on the shoulders to a patient receiving an intravenous infusion in the forearm. Which should the nurse do?

Insert the IV bag and tubing through the sleeve from inside of the gown first.

A home-care nurse observes the spouse of a patient inserting a rectal suppository. Which behavior indicates that the nurse must provide further teaching about suppository administration?

Inserts the suppository while the patient bears down

A nurse is attending a class about a new intravenous pump presented by the hospital staff education department. Which is this type of educational program?

Inservice education program

A home-care nurse is helping a patient with short-term memory loss with how to remember to take multiple drugs throughout the day. Which should the nurse do when teaching this patient?

Instruct the patient to put medications in a weekly organizational pill container

A patient asks the nurse, "What is a Living Will?" The nurse should respond that it is a document that:

Instructs a physician to withhold/withdraw life-sustaining procedures if death is near

A nurse evaluates a patient's fluid balance by monitoring the patient's intake and output. Which must the nurse understand about the ratio of the patient's fluid intake to output?

Intake should be slightly more than the output

The nurse is caring for a geriatric client in the home setting. Due to geriatric changes decreasing thirst, the nurse is likely to see a decrease in which fluid location that contains the most body water?

Intracellular fluid

Which human response identified by the nurse is an example of objective data?

Irregular radial pulse of 50 bpm

An essential concept related to understanding the Nursing Process is that it:

Is dynamic rather than static

A nurse is preparing a client for endotracheal intubation. The anesthesiologist has ordered an anticholinergic medication for this client. What is an action of this medication?

It decreases respiratory secretions.

When assessing lung sounds, the nurse applies the stethoscope's chest piece to the client's upper back, but avoids placing it over the scapulae or ribs. How does this intervention help in the assessment?

It facilitates hearing sounds in the upper and lower lobes.

A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The nurse explains to the client that COPD is a chronic disease. Why is COPD considered a chronic disease?

It has a gradual onset and lasts for a long time.

. A nurse is explaining to an insomniac client the effect of a prescribed medication and the different phases of sleep. Which statement is true for non-rapid eye movement (NREM) sleep?

It is called slow wave sleep.

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation?

It provides quick access to abnormal findings.

An obese resident of a nursing home who is receiving a 1,500-calorie weight reduction diet has not lost weight in the past 2 weeks. Which should the nurse do first ?

Keep a log of the oral intake for 3 days.

A client has been admitted to the health care facility for less than 24 hours for observation. The client has a gold ring, watch, reading glasses, and other personal belongings. What care should the nurse take with regard to these objects?

Keep the client's belongings secured in a locker.

A nurse is caring for a patient who is blind in the left eye and visually impaired in the right eye. Which actions should the nurse employ to promote communication with this patient?

Knock on the door and request permission to enter before approaching the patient

Which concepts associated with rest and sleep must the nurse consider when planning nursing care? Select all that apply.

Lack of awareness of the environment increases with sleep. & Sleep requirements increase during stress.

A nurse is observing the prescribed therapeutic activity of a middle-aged client who underwent a mastectomy to control her breast cancer. Which active exercises or therapeutic activities should the client perform?

Learn to comb her hair independently with the arm on the surgical side.

A nurse uses computer-assisted instruction as a strategy when providing preoperative teaching. Which should the nurse explain to preoperative patients is the greatest advantage of computer-assisted instruction?

Learners can progress at their own rate.

A nurse is planning a teaching plan for an older adult. Which common factors among older adult patients must be considered? Select all that apply.

Learning may require more energy & Sensory decline occurs as one ages.

A nurse is caring for a patient who had an abdominal hysterectomy. Which intervention best prevents postoperative thrombophlebitis?

Leg exercises 10 times per hour when awake

The patient has severe hyperthyroidism and will have surgery tomorrow. What assessment is most important for the nurse to assess in order to detect development of the acid-base imbalance for which the patient has highest risk?

Level of consciousness

Which is the last step in making an occupied bed that the nurse should teach a nursing assistant?

Lowering the height of the bed toward the floor

Which is the purpose of the use of humor by a nurse when interacting with a patient?

Maintain a balanced perspective

An Anglo American client reports to the primary health care facility with symptoms of fever, cough, and running nose. While interviewing the client, which of the following points should the nurse keep in mind?

Maintain eye contact while talking.

The nurse is caring for a patient with a fever. Which is a well-designed goal for this patient? The patient will:

Maintain fluid intake sufficient to prevent dehydration

A client has been ordered to undergo a step test. Which arrangement is of greatest importance during a step test?

Make arrangements for cardiopulmonary resuscitation personnel.

A patient falls while getting out of bed unassisted. When completing an Incident Report, the nurse understands that its main purpose is to:

Make data available for quality control analysis

A nurse is assessing a patient to determine educational needs. Which is most important for the nurse to consider?

Make no assumptions about the patient.

What is the most appropriate resource to include when planning to provide patient education related to a goal in the psychomotor domain?

Manikin practice sessions

A client admitted to a health care facility uses a walker for support. What is the nurse's responsibility with regard to the walker when admitting the client to the nursing unit?

Mark the client's walker with a large, easily readable label.

Based on the significant effects of chronic idiopathic fatigue, what is the nurse's priority assessment?

Mental health evaluation

A nurse is taking care of a client during the immediate postoperative period. Which duty performed during the immediate postoperative period is most important?

Monitor the client for complications.

There are discharge criteria for patients in the post-anesthesia care unit (PACU) regardless of the type of anesthesia used and additional criteria for specific types of anesthesia. Which is the criterion specific for the patient who has received spinal anesthesia?

Motor and sensory function returns

Profuse smoke is coming out of the heating unit in a patient's room. Which should the nurse do first ?

Move the patient out of the room

The nurse is assigned a client with calcium level of 4.0 mg/dL. Which system assessment would the nurse ask detailed questions?

Neurologic system

An elderly client with limited mobility is being treated for a pressure ulcer that developed while the client was in a residential facility. A hydrocolloid dressing has been applied to the client's ulcer in order to ensure a moist wound environment. What is the primary rationale for keeping a wound moist?

New body cells grow most quickly in a moist environment.

A 64-year-old client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and is lethargic. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for this client?

No, sodium intake should be restricted.

The nurse palpates swollen nodes in a patient's neck who presented to the clinic with complaints of fatigue lasting at least 2 weeks. What is the nurse's best action?

Notify the healthcare provider.

A nurse is working with a client who is in postoperative day 2 following a total knee replacement. The client has briefly mobilized using a wheeled walker and with the assistance of the physical therapist. However, the client is reluctant to progress further with mobilization for fear of injuring herself. In response to this, the nurse has liaised with the physical therapist to create a plan of care that creates specific goals for the client's mobility. In doing so, this nurse has exemplified what role?

Nurse as collaborator

A nurse is providing health education to a client who has been admitted to the health care facility. How can the nurse best determine that the education standards have been met?

Observe changes in the client's behavior after teaching.

The nurse is adding the intake and output results for a client diagnosed with dehydration. The nurse notes a 24-hour intake of 1500 mL/day between oral fluids and intravenous solutions. The output total is calculated as 2800 mL/day from urine output, emesis, and Hemovac drainage. Which nursing action is best to maintain an acceptable fluid balance?

Offer a prescribed antiemetic medication.

The nurse is adding the intake and output results for a client diagnosed with dehydration. The nurse notes a 24-hour intake of 1500 mL/day between oral fluids and intravenous solutions. The output total is calculated as 2800 mL/day from urine output, emesis, and Hemovac drainage. Which nursing action is best to maintain an acceptable fluid balance?

Offer a prescribed antiemetic medication. ✓

When describing patient education approaches, the nurse educator would explain that informal teaching is an approach that involves which quality?

Often occurs one-to-one

A patient has been admitted for a skin graft following third degree burns to the bilateral calves. The plan of care involves 3 days inpatient and 6 months outpatient treatment, to include home care and dressing changes. When should the nurse initiate the educational plan?

On admission, along with the initial assessment

The telehealth nurse receives a call from a caller who states that upon entering the home, two confused family members have been found with a bright cherry red skin color. They are reporting nausea and headache, and are unable to move. Which initial direction will the nurse provide?

Open doors and windows.

A nurse is caring for an older adult client who is unable to walk without a support due to knee pain. During his initial assessment, however, the client does not mention pain. Which belief common in older adult clients may cause them to underreport their pain?

Pain is a normal part of aging.

A nurse who works in a high-acuity setting is conscious of ensuring that clients' pain assessments and pain control regimens are highly individualized. Which statement about pain threshold is most accurate?

Pain thresholds tend to be the same among healthy people.

The daughter of an elderly man who resides at a long-term care facility has confronted the nurse with the fact that her father has not been receiving full baths on a frequent basis and has instead been receiving partial baths. What is an acceptable rationale for providing partial baths rather than full baths to older adult clients?

Partial baths deplete less of the client's skin oils than a full bath.

A patient received conscious sedation during a colonoscopy. Which should the nurse expect regarding the patient's experience with this procedure?

Patient will be sleepy but able to follow verbal commands

The nurse is teaching the caregiver of an adolescent child about safety. Which teaching will the nurse include?

Peer pressure causes children of this age to task risks.

The client reports, "I have a few drinks with friends every week." Which nursing action exemplifies using a focused assessment?

Perform an initial history specific to substance use

A primary health-care provider orders a vest restraint for a patient. Which should the nurse do first when applying this restraint?

Perform an inspection of the patient's skin where the restraint is to be placed.

A nurse must assess for the presence of bowel sounds in a postoperative patient. Which technique should the nurse employ to obtain accurate results when auscultating the patient's abdomen?

Perform auscultation before palpation of the abdomen.

An operating room nurse is caring for a client who will soon undergo an appendectomy. Which handwashing technique is most appropriate for the nurse to use when caring for this client?

Perform surgical hand scrub using detergent.

A nurse is caring for a client at the local health care facility. What ensures that the HIPAA legislation is implemented at the facility?

Place light boxes for examining x-rays with the client's name in private areas.

The nurse makes an erroneous entry into the written health record. What is the appropriate nursing action?

Place one line through the entry, and initial.

A nurse is to administer an oil-retention enema, a tap-water enema, and a returnflow enema to three different patients. Which nursing interventions should be performed with all three enemas? Select all that apply.

Place the patient in the left side-lying position & Pull the curtain around the patient's bed and drape the patient & Use water-soluble jelly to lubricate the tip of the rectal probe

The nurse is obtaining a patient's blood pressure. Which information is most important for the nurse to document?

Position of the patient if the patient is not in a sitting position

. A nurse is caring for a debilitated female patient with nocturia. Which nursing intervention is the priority when planning to meet this patient's needs?

Positioning a bedside commode near the bed

A nurse is assessing a client receiving IV fluid and electrolyte therapy. Which laboratory test result will the nurse prioritize?

Potassium 2.1 mEq/L

The nurse is reviewing client lab work for a critical lab value. Which value is called to the physician for additional orders?

Potassium: 5.8 mEq/L

A nurse holds a bottle with the label next to the palm of the hand when pouring a liquid medication. Which is the rationale for this action?

Prevent soiling of the label by spilled liquid.

A nurse is caring for a patient recovering from abdominal surgery. Which nursing actions are effective in facilitating ventilation? Select all that apply.

Preventing abdominal distention & Encouraging fluid intake & Ensuring that an incentive spirometer is used every hour when awake

A nurse in the operating room is to position a patient for surgery. Which factor is most important for the nurse to consider?

Provide for adequate thoracic expansion

A nurse is caring for a patient who has type 1 diabetes and an ulcer on the big toe of the right foot. The nurse plans to review how to perform self-blood glucose monitoring, self-administer an injection, and apply a sterile dressing to the ulcer on the toe. The nurse identifies that the patient is a kinesthetic learner. Which teaching strategy is most appropriate for the nurse to use with this patient?

Provide occasions to touch and handle equipment

The nurse identifies that the greatest risk for a wound infection exists for a patient with a:

Puncture of the foot by a nail

A patient tells the nurse, "I think I have an ear infection." The nurse should assess this patient for which objective human response to an ear infection?

Purulent drainage

A nurse is assisting a patient with a regular bedpan. Which nursing actions are essential? Select all that apply.

Raise the side rails on both sides of the bed after the patient is positioned on the bedpan. & Elevate the head of the bed to the Fowler position after the patient is on the bedpan & Remain outside the curtains of the bed until the patient is done using the bedpan

The nurse must awaken a patient from Stage 4 non-rapid eye movement sleep in order to prepare the patient for a procedure. The patient is disoriented. What is the nurse's best action?

Re-assess the patient's orientation

A nurse suggests that an elderly client perform exercises in water. What is a benefit for older adults of performing exercise in water?

Reduces stress to the joints

A patient with hypertension is given discharge instructions to take the blood pressure every day. The nurse is evaluating a family member taking the patient's blood pressure as part of the patient's discharge teaching plan. The nurse identifies that further teaching is necessary when the family member:

Releases the valve on the manometer so that the gauge drops 10 mm Hg per heartbeat

The nurse is educating a client and family about home safety. Which teaching will the nurse include? (Select all that apply.)

Replace rubber tips on cane as soon as they become worn or dirty. & Consider adding grab bars to shower or tub. & Assess for adequate lighting so client can see clearly when walking.

A school nurse is teaching a class of adolescents about avoiding smoking and includes role-playing as a creative learning activity. Which is the primary reason for using role-playing?

Requires active participation by the learner

A client was admitted to the unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and family? Select all that apply.

Respond to thirst. & Drink at least eight glasses of fluid each day. & Drink water as an inexpensive way to meet fluid needs.

When two nursing diagnoses appear closely related, what should the nurse do first to determine which diagnosis most accurately reflects the needs of the patient?

Review the defining characteristics

A nurse is providing care for a client who is unconscious following a traumatic brain injury suffered in a motor vehicle accident. The nurse provides thorough oral care to the client on a regular basis. When providing this care, the nurse should take specific action to reduce the client's risk of what nursing diagnosis?

Risk for Aspiration

A client with HIV has been admitted to a health care facility. Which nursing diagnosis should be of the highest priority, keeping in mind the client's condition?

Risk for infection

Which nursing action is appropriate when administering an analgesic?

Seek a new prescription after two doses that do not achieve a tolerable level of relief.

A nurse suspects that an older adult may have a fluid and electrolyte imbalance. Which assessment best reflects fluid and electrolyte balance in an older adult?

Serum laboratory values

A nurse is planning a weight-reduction program with an obese patient. Which should the nurse anticipate will be the most important component that will determine the success or failure of this program?

Setting realistic goals

A nurse is caring for a patient with a nasogastric tube attached to suction. What is the most important nursing action in relation to the nasogastric tube?

Setting suction at the ordered level

A nurse is preparing to administer potassium to a client. Which reaction should the nurse carefully monitor the client for if the use of salt substitutes is documented in the client's record?

Severe hyperkalemia

A patient has a right abdominal incision. Which should the nurse teach the patient to do when getting out of bed? Select all that apply.

Sit on the side of the bed for a few minutes before moving to a standing position. & Use the left arm to push up to a sitting position on the side of the bed & Exit from the left side of the bed.

Which clinical manifestation indicates that a further nursing assessment is necessary to determine if the patient is having difficulty swallowing? Select all that apply.

Slurred speech & Debris in the buccal cavity & Drooling

A nurse in the post-anesthesia care unit at 3 p.m. receives report from the nurse who is completing the day shift. The following information about a 65-year-old man who was admitted to the unit at 1:30 p.m. after repair of a double inguinal hernia is reported. Which information does not meet the standard criteria for discharge from the unit? Vital Signs Temperature: 99 o F, temporal Pulse: 98 beats per minute Respirations: 30 breaths per minute Blood pressure: 170/90 mm Hg Physical Assessment Abdominal dressing dry and intact; IV 0.9% sodium chloride at 125 mL per hour, site in left hand dry and intact, free of complications. Removed oral airway at 2 p.m.; gag reflex present; coughing, deep breathing and moving all extremities on command. Urinary catheter draining more than 50 mL per hour; bowel sounds absent. Oxygen Status Oxygen saturation 97% with nasal cannula at 2 L; breathing freely on own

Stability of vital signs

A nurse is performing preoperative teaching a week before surgery. The patient is taking 650 mg of aspirin twice a day for arthritis. Which should the nurse instruct the patient to do?

Stop taking the aspirin 5 days before surgery

A nurse is monitoring a client who is receiving IV electrolytes. Which priority action should the nurse take if the following are noted on the assessment of the intravenous site: redness, edema, warmth, and pain?

Stop the current infusion and restart the infusion in another vein.

Which are treatment related causes of fatigue? (Select all that apply.)

Surgery & Side effects of medications & Chemotherapy & Radiation therapy

A nurse needs to restrain a client who may be harmful to himself. What is the priority nursing action when applying restraints?

Take a physician's order for restraining.

A client taking a diuretic twice daily for treatment of hypertension reports being awakened often by a full bladder. What teaching regarding the diuretic will the nurse provide?

Take before 6:00 PM at night.

During the evaluation step of the Nursing Process, the nurse must

Take corrective action

A patient states that when turning on an electric radio a strong electrical shock was felt. Which should the nurse do first ?

Take the patient's apical pulse

The nurse is caring for a client with a latex allergy. Which nursing interventions are appropriate? (Select all that apply.)

Teach client to wear Medic-Alert bracelet. & Apply an allergy-alert identification bracelet on the client. & Communicate to the interdisciplinary healthcare team to use nonlatex equipment. & Flag the chart and room door.

The nurse is caring for a client who experiences automatic behaviors associated with narcolepsy. What is the priority nursing intervention?

Teach client's spouse to keep car keys in an undisclosed location at night.

A nurse is completing vital signs on a client who was brought into the emergency department by ambulance. Which assessment findings require immediate attention? (Select all that apply.)

Temperature is 101.4° F (38.6 C.). & Heart rate is 130 beats per minute. & Oxygen saturation is 90%. & Pain is 8 on scale of 1-10

A nurse witnesses a traffic accident in which a child is badly hurt. The nurse dresses the open wounds sustained by the child. The family tries to give monetary compensation, which the nurse refuses. Later, in the hospital, the child develops complications due to infection in the wound. The family holds the nurse responsible for the complications and wants to file a lawsuit. Which of the following statements is true regarding the Good Samaritan law?

The Good Samaritan law will provide legal immunity to the nurse.

An Asian American client is scheduled for discharge after being diagnosed with type 1 diabetes mellitus. Before leaving the health care facility, the nurse demonstrates the technique of self-administration of insulin and explains the importance of the client's prescribed insulin regimen in controlling blood sugar levels. What may the nurse conclude if the client continues to stare blankly?

The client disapproves of the insulin treatment.

A middle-age client with cancer has been prescribed patient-controlled analgesia (PCA). The nurse caring for the client explains the functioning of PCA. What is the main advantage of PCA?

The client is actively involved in pain management.

A client has come to a health care facility for autologous donation of blood. Which is a criterion for autologous donation?

The client must have a hematocrit that is within normal range.

During a round at night, the nurse finds that a client is missing from his room. The client returns early next morning. What procedure is followed by the health care facility with regard to this client?

The client needs to repeat the admission procedure.

A client states that the client is "fed up" with the care that the client has been receiving in the hospital and plans to leave immediately. What procedure is followed with regard to this client?

The client needs to sign a form releasing the physician and agency from responsibility.

An elderly client fell 2 days ago on the sidewalk near home and has been admitted to the hospital with a hip fracture. Since the subsequent surgery, the client he has been insistent on wearing their own sweater and cap. The nurse is aware that the client is not cold, has no cognitive deficits, and has participated cooperatively in all aspects of his treatment. What is the most plausible rationale for the client's action?

The client wishes to maintain and assert their personal identity.

A client is scheduled for thoracentesis. The nurse assesses that the client appears anxious about the procedure and needs honest support and reassurance. What is the most appropriate response by the nurse to this client?

The needle causes pain when it goes in, but I will be by your side throughout and will help you hold your position."

A nurse is aware that clear and accurate communication is necessary whenever clients are transferred or referred. Which situation best demonstrates a referral?

The nurse arranges for a client with a diabetic foot ulcer to see a podiatrist in community.

A nurse enters a client's room and finds that the client is lying on the floor. The nurse makes the client comfortable on the bed and completes an examination. She informs the physician and the nursing supervisor about this incident and also completes an incident report. Which action by the nurse indicates correct knowledge of handling an incident report?

The nurse documents a complete description of the happenings in the client's records.

A home care nurse is caring for a paralyzed client who needs regular position changes and back massages. A man identifying himself as a family friend inquires if he can be of any help to the family. What should be the nurse's response be?

The nurse should ask the man to talk to the family directly.

A nurse and an older adult client with chronic back pain are in the working phase of the nurse-client relationship. Which activity occurs in the working phase?

The nurse tries to avoid hampering the client's independence.

The home care nurse is assessing an older patient diagnosed with mild cognitive impairment (MCI) in the home setting. Which information is of concern?

The patient has lost 10 pounds (4.5 kg) during the last month.

An 81-year-old resident of an intermediate care facility has been assessed and the nurse believes that a move to a skilled nursing facility may be justified. What aspect of the resident's health would warrant a move to a skilled nursing facility?

The resident has developed pressure ulcers on the backs of the heels.

A nurse is caring for two patients. One of the patients has a Jackson-Pratt drain and the other patient has a Hemovac drain. Which does the nurse understand is the difference between these two drains?

The size of the collection container

Which factor is unique to malpractice when comparing negligence and malpractice?

There is a contractual relationship between the nurse and patient

The nurse is caring for a 10-year-old client with gastritis. During the health education, which of the following points should the nurse keep in mind with regards to the characteristics of pedagogic learners?

They respond to competition.

The male Navajo client comes to the clinic complaining of chest pain and has a pouch filled with objects around his neck. Which statement best supports the nurse allowing the client to wear the pouch?

This is a cultural practice shared by many Navajo clients, and the nurse should not remove it unless it interferes with the client's care.

A client admitted to the health care facility for minor surgery is given a booklet by the nurse about the health care facility. Which of the following is a purpose of this booklet?

To orient the client to the facility

The nurse is caring for a male patient with a urinary elimination problem. Which is the most accurately stated goal? "The patient will:

Transfer independently and safely to a commode before discharge."

A nurse is assessing a patient who is being admitted to the hospital. Which is the most important information that indicates whether the patient is at risk for physical injury?

Two recent falls that occurred at home

How often should "docusate sodium 100 mg PO bid" be given?

Two times a day

Which is the primary reason why nurses attend continuing education programs?

Update professional knowledge.

A primary health-care provider orders a urine specimen for culture and sensitivity via a straight catheter for a patient. Which should the nurse do when collecting this urine specimen?

Use a sterile specimen container.

A nurse is teaching a patient who has impaired vision to self-inject insulin. Which should the nurse do to facilitate the teaching- learning process? Select all that apply

Use audio learning materials & Obtain an order for automatic-stop syringes & Provide written information in large print

The nurse is caring for a client who is a recent immigrant to the country. The family is present in the room and one member of the family speaks English. Which should the nurse implement to complete the admission assessment?

Use the medical interpretation phone to ask the admission questions.

When the nurse brings pills to a patient, the patient is unable to hold the paper cup with the medications. Which should the nurse do?

Use the paper cup to introduce the pills into the patient's mouth

When caring for a client at a health care facility, the nurse discovers that the client is unable to read or write. Which of the following teaching approaches is most useful for the client?

Use verbal and visual modes of communication.

The nurse is delegating ambulation of a client with generalized weakness to the unlicensed assistive personnel (UAP). Which teaching will the nurse provide? (Select all that apply.)

Utilize a gait belt around the client's waist. & When available, use parallel bars for support.

The nurse is transferring a stroke client to a long-term care facility. The client lived at home prior to the illness, but now is aphasic and unable to provide independent care. Which action made by the nurse demonstrates appropriate completion of the client's medication reconciliation?

Verify current medications with the client's physician.

. A nurse is assessing a client's daily laboratory results and notes an electrolyte imbalance. The nurse would assess the client for which potential events that can contribute to the imbalance? Select all that apply.

Vomiting & Drug administration & Diagnostic tests & Surgery

A nurse must administer a medication into the ear of an adult. Which should the nurse do to limit patient discomfort when administering ear drops?

Warm the solution to body temperature

A nurse is assessing a client during a health care camp. The nurse observes that the client has poor hygiene and an itchy, infected scalp. What should the nurse ask the client to do?

Wash hair daily.

To interrupt the transmission link in the chain of infection, the nurse should:

Wash the hands before and after providing care to a patient

A client with TB has been discharged from the health care facility. What care should be taken with regard to cleaning the bed linens used by the client during his stay at the facility?

Wash them with boiling water.

A nurse is informing a nursing student about the Centers for Disease Control and Prevention (CDC) guidelines for hand asepsis. Which guideline is in compliance with the CDC guidelines for hand washing?

Washing when hands are visibly soiled

A nurse is required to clean the open wounds of a client who has been involved in an automobile accident. What intervention would the nurse need to perform when cleaning a client's open wounds to protect the nurse from infection?

Wear a clean pair of latex or latex-free gloves.

When caring for a client with a bacterial respiratory infection and an active cough, what action should the nurse take in order to prevent becoming infected?

Wear a mask when caring for the client.

The nurse must take a patient's rectal temperature. Which should the nurse do?

Wear gloves throughout the procedure

A nurse is assessing a patient's fluid status. Which assessments indicate that the patient has a deficient fluid volume? Select all that apply.

Weight loss & Negative balance of intake and output & Flat neck veins

A nurse is observing the housekeeping staff when they are cleaning a health care facility. Which principle should the housekeeping staff follow for medical asepsis?

Wet-mop floors to avoid distributing microorganisms.

The nurse in the clinic must obtain the vital signs of each patient before each patient is assessed by the practitioner. The nurse should obtain a temperature via the rectal route for a patient:

Who is a mouth breather

When caring for a client with an open wound, which characteristic should the nurse observe if the wound heals by primary intention?

Wound edges are directly next to each other.

The nurse understands that an example of an iatrogenic infection is a:

Wound infection caused by unwashed hands of a caregiver

When assessing the sensory skin perception of an older adult client, the nurse strokes the skin with a cotton ball at various places on both sides of the body. What information does the nurse obtain from this assessment?

ability to identify fine touch

Which abbreviation indicates that the primary health-care provider wants a medication administered before meals?

ac

A nurse is caring for older adult clients. Which is the most important safety issue in older clients?

accident falls

Components of a professional identity in nursing include which attributes? (Select all that apply.)

accountability & advocacy & autonomy & competence

The nurse is correct to state that a client's body needs to have adequate nutrition to maintain energy. Which type of transport of dissolved substances requires adenosine triphosphate (ATP)?

active transport

. A client who was a victim of domestic violence for years states to the nurse, "I know I should not feel this way, but every time I think of my former spouse, I get a horrible headache and have to go lie down." Which nursing intervention reflects practice according to the Gate-Control Theory?

administering backrub when client's head hurts

The risk management coordinator is preparing a program on the factors that contribute to falls in a hospital setting. Which factor that most often contributes to falls should be included in this program?

advanced age of patients

The nurse in the Emergency Department is engaging in an initial assessment of a patient. Which assessment takes priority?

airway clearance

A client visits a health care facility reporting loss of appetite following a prolonged illness. How should the nurse document the client's condition?

anorexia

A nurse is caring for a group of patients with a variety of urinary problems. Which patient's physical response should cause the most concern?

anuria

A nurse visits an older adult client at home and assesses the safety of the client's environment. Which article can be a threat to the client's safety?

area rugs kept on the stairs without carpet

A client who was a victim of domestic violence for years states to the nurse, "I know I should not feel this way, but every time I think of my former spouse, I get a horrible headache and have to go lie down." Which nursing intervention reflects practice according to the Pattern Theory?

asking client how sensory stimuli produces pain

The nurse says, "If you do not let me do this dressing change, I will not let you eat dinner with the other residents in the dining room." This is an example of:

assault

The nurse enters the room and the client is grimacing and guarding the abdomen. The client reports, "I have pain." What is the nurse's first priority?

assessing the client's level of pain

An 18-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to:

automobile accidents.

A patient suffered a brain injury from a motor vehicle accident and has no brain activity. The patient has a living will which states no heroic measures. The family requests that no additional heroic measures be instituted for their son. The nurse respects this decision in keeping with which principle?

autonomy

A client's hand was severely wounded upon coming in contact with a running lawn mower blade. The nurse notes that large amounts of flesh are missing, and the bones of two fingers are visible. How will the nurse document this assessment finding?

avulsion

An elderly client is admitted to a health care facility for the treatment of frequent seizures. What should the nurse use when attending to the personal hygiene of a client with seizures?

bag bath

An oncology nurse is caring for a client suffering from metabolic encephalopathy and end stage kidney disease. The client has no known family and no advanced directives. Upon entering the room, the nurse observes the client is pale and has no spontaneous respiration. What is the priority action the nurse should take?

begin CPR

A nurse is caring for an elderly client with muscle atrophy. Which condition can lead to muscle atrophy in elderly clients?

being bedridden for 1 or 2 days

A nursing student is conducting a survey of fellow nursing students. Which ethical concept is the student following when calculating the risk-to-benefit ratio and concluding that no harmful effects were associated with a survey?

beneficence

A postsurgical client is recovering in hospital following bowel surgery. The client's family is eager to bring the client some of the client's favorite foods to make the client's stay more pleasant and has asked the nurse whether this practice is acceptable. The client is currently on a clear liquid diet, which will be changed as the client tolerates intake. What food item is currently acceptable within this hospital diet?

black tea

patient has a serious vitamin K deficiency. For which adaptation should the nurse assess this patient?

bleeding gums

When collecting a urine sample from a client for examination, the nurse notes that the sample appears reddish-brown in color. What could cause this variation in color of the urine?

blood

An adult patient's vital signs are: oral temperature 99°F, pulse 88 beats per minute with a regular rhythm, respirations 16 breaths per minute and deep, and blood pressure 180/110 mm Hg. Which sign should cause concern?

blood pressure

The nurse is caring for a client who had an outpatient procedure. Which assessment finding indicates to the nurse that the client may be ready for discharge to home?

blood pressure 118/70 mm Hg, respirations 18 breaths per minute

The occupational nurse is assessing an employee's vital signs at rest. Which finding requires nursing intervention?

blood pressure 140/90 mm Hg

The nurse is caring for a patient diagnosed with amyotrophic lateral sclerosis. The nurse should assess for which priority problem?

bradypnea

Which ambulatory aid could a nurse suggest to assist a client who has weakness in one side of his body?

cane

A 2-g sodium diet is ordered for a patient with hypertension. Which foods should the nurse teach the patient to avoid? Select all that apply.

canned tuna fish & american cheese

A patient receiving a diuretic is encouraged to increase the intake of potassium. Which foods selected by the patient indicate that the teaching is understood? Select all that apply.

cantaloupe & fresh salmon

A nurse is assessing a patient's bilateral pulses for symmetry. Which pulse site should not be assessed on both sides of the body at the same time?

carotid

The nurse is assessing a patient's bilateral pulses for symmetry. However, the nurse should not assess which pulse sites on both sides of the body at the same time?

carotid

The nurse is caring for a client with hypertension, and only documents a blood pressure of 170/100 mm Hg when all other vital signs are normal. This reflects what type of documentation?

charting by exception

A nurse needs to count a client's apical heart rate. Which assessment site is most suitable for counting the apical heart rate?

chest

A nurse has entered the room of a resident at the care facility and discovered that the resident has lit some paper on fire in the trash can. What types of fire extinguisher are appropriate for putting out this fire? (Select all that apply.)

class A & class ABC

A client reports to a health care facility with reporting abdominal pain and vomiting. The client's wife informs the nurse that the client had gone out for dinner the previous night. Which of the following would be the primary source of assessment data?

client himself

A nurse is caring for four adult clients. Which client would the nurse assess first?

client with a respiratory rate 32/min

When caring for a client, the nurse observes that the client enjoys reading books and magazines. In which of the following learning domains does the client's learning style fall?

cognitive domain

A nurse is teaching a preschool-aged child. Which teaching method is most appropriate for the nurse to use when teaching a child in this age group?

coloring books

An obese client has been advised to begin a program of fitness exercise. In preparation for the program, the nurse has taught the client the concept of metabolic energy equivalents (METs). An understanding of METs allows the client to:

compare the relative intensity of different forms of activity.

A nurse is caring for a patient with a high fever secondary to septicemia. The primary health-care provider orders a cooling blanket (hypothermia blanket). Through which mechanism does the hypothermia blanket achieve heat loss?

conduction

The nurse is caring for a patient with a high fever secondary to septicemia. When the physician orders a cooling blanket, the nurse understands that it is used to achieve heat loss via:

conduction

The client has been assessed by the emergency department physician and nurse. The physician wants the client to be observed overnight. The client refuses and wants to leave. What are the components of a properly executed against medical advice (AMA) discharge based on this scenario? (Select all that apply.)

consent properly documented & all risks disclosed & capacity to refuse

A patient is positive for Clostridium diffi cile. The nurse should institute the isolation precaution known as:

contact

The nurse is caring for a client with laboratory values indicating dehydration. Which clinical symptom is consistent with the dehydration?

dark, concentrated urine

A nurse is caring for a patient who has a reduced fluid intake. The nurse assesses the patient for which response to this reduced fluid intake?

decreased urine output

A nurse is teaching a postoperative patient deep breathing and coughing exercises. Which method of instruction is most appropriate in this situation?

demonstration

A nurse is planning to engage a patient in a program to learn about a newly diagnosed illness. Which psychosocial response to the illness will have the greatest impact on the patient's future success of learning?

denial

An unconscious patient is treated in the emergency department for head trauma. The patient is unconscious and on life support for 2 weeks prior to making a full recovery. The initial actions of the medical team are based on which ethical principle?

deontology

A nurse is assessing a client who seems to have developed a hearing impairment after working at a construction site for a few months. The nurse is using the Weber test to assess the client's hearing acuity. What is the purpose of the Weber test?

determines the equality or disparity of bone-conducted sound

When considering the Nursing Process, the nurse understands that the word "observe" is to "assess" as the word "determine" is to:

diagnose

The nurse comes to the conclusion that a patient's elevated temperature, pulse, and respirations are significant. What step of the Nursing Process is being used when the nurse comes to this conclusion?

diagnosis

A nurse is caring for patients with a variety of nutrition-related problems. Which problem eventually may require a patient to have a nasogastric feeding tube inserted?

difficulty swallowing

A man with numerous comorbid health problems has presented to the clinic for a scheduled appointment. The man states that he has been awakening frequently during the night to void. The nurse should inquire about the time of day that the client is taking his prescribed:

diuretic

A nurse is caring for a client who is reporting nausea. Which is a sign of nausea?

dizziness and perspiration

A nurse uses an open drain to drain the blood and drainage from a client's wound. The nurse knows that an open drain functions in which way?

drainage occurs passively by gravity and capillary action

A nurse is administering prescribed carbamide peroxide to a client with excess cerumen. Which condition may have prompted this treatment?

ear wax accumulation leading to hearing loss

The post-anesthesia care unit (PACU) nurse has just received a client who underwent coronary artery bypass grafting (CABG). Which will the nurse assess while the client is in the PACU? (Select all that apply.)

ease of breathing & drains and drainage characteristics & condition of incision & urine output & pain level

A patient has a wound infection. Which local human response should the nurse expect to identify?

edema

A client is prescribed normal saline IV. The nurse will exercise caution after noting which disorders in the client's medical record? Select all that apply.

edema & hypoproteinemia & renal impairment

A nurse is giving a back rub. Which stroke is most effective in inducing relaxation at the end of the procedure?

effleurage

A male client is scheduled to have a suprapubic catheter inserted as part of his treatment for prostate cancer. The nurse is explaining the preoperative preparation that will be necessary, including hair removal. Hair removal will be accomplished with:

electric clippers

The nurse is caring for a client with heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process?

elevated blood pressure

A family has lost a member who was treated for leukemia at a nursing unit. The nurse provides emotional support to the family and counsels them to cope with their loss. Which quality should the nurse use in this situation?

empathy

A nurse is caring for an older adult client hospitalized following a hip fracture. Which actions made by the nurse will promote the development of a therapeutic relationship? (Select all that apply.)

encouraging the client to talk about the client's life & asking the client when the client would like to have the bed linens changed

A nurse is teaching a patient about the importance of balancing protein, carbohydrates, and fats in the diet. The nurse identifies that the teaching about carbohydrates is understood when the patient states that carbohydrates are known for providing which of the following

energy

The nurse is caring for the same client this week as last week, and the week before. Continuity of care is the process in which the client and the care team are involved in ongoing healthcare management. What is the function of continuity of care?

ensuring quality of care over time

The nurse identifies that a patient has an inflammatory response. Which local patient adaptation supports this conclusion?

erythema

During which of the five steps in the Nursing Process does the nurse determine whether outcomes of care are achieved?

evaluation

A client admitted to the health care facility is assessed using a Minimum Data Set. How often is the Minimum Data Set repeated for a client?

every 3 month

A health care agency is applying for accreditation and the accrediting agency is conducting audits of randomly selected medical records. To support the agency's accreditation, these medical records should include:

evidence that nursing interventions have been evaluated in terms of the client's response.

The nurse is caring for a patient who is experiencing an increase in symptoms associated with multiple sclerosis. Which term best describes a recurrence of symptoms associated with a chronic disease?

exacerbation

A nurse is explaining the different procedures used to break the chain of infection to a nursing student. In which link in the chain of infection should a nurse provide special attention to the respiratory and gastrointestinal tracts?

exit route

A client has a diagnosis of stage 4 non-small cell lung cancer (NSCLC). The nurse consulted social services for discharge planning regarding appropriate level of care needed after chemotherapy. The client is able to provide partial self-care and will need pain medication. What setting is most appropriate for the client?

extended care

A client who is disabled due to stroke is discharged from a health care unit and an LPN is assigned to provide nursing care to the client at home. This is an example of which kind of care?

extended care

A nurse on the unit makes an error in the calculation of the dose of medication for a critically ill patient. The patient suffered no ill consequences from the administration. The nurse decides not to report the error or file an incident report. The nurse is violating which principle of ethics?

fidelity

35. Women who are given the job of caretaker for aging relatives are subject to caregiver strain due to

fixed gender roles.

A nurse is caring for two patients; one has oliguria and the other has polyuria. Which is the priority problem that is a concern for the nurse regarding both of these patients?

fluid volume deficit

A nurse is caring for a 65-year-old male client who is postoperative day 1 following a total hip replacement. Which should the nurse use in order to assist the client to eliminate urine?

fracture pan

The nurse understands that evaluation most directly relates to which aspect of the Nursing Process?

goal

A culturally competent nurse is planning to teach a patient about a new regimen of self-care. Which must the nurse assess first about the patient before implementing the teaching plan?

health beliefs

Barriers to patient education the nurse considers in implementing a teaching plan include which factor?

hunger and pain

A nurse is caring for a patient who has dependent edema. Which pressure has caused the excess fluid in the interstitial compartment?

hydrostatic pressure

A patient is admitted to the hospital for a fever of unknown origin. The nursing assessment reveals profuse diaphoresis, dry, sticky mucous membranes, weakness, disorientation, and a decreasing level of consciousness. Which electrolyte imbalance does this data support?

hypernatremia

The nurse is caring for a client who has been admitted with a possible clotting disorder. The client is complaining of excessive bleeding and bruising without cause. The nurse knows to take extra care to check for signs of bruising or bleeding in what condition?

hypocalcemia

Which of the following conditions does the nurse need to confirm when he or she taps the facial nerve of a client who has dysphagia?

hypomagnesemia

The nursing instructor is observing a nursing student who is about to administer a medication. Which nursing student behavior concerning client identification does the nursing instructor validate as appropriate?

identifies client's full name and date of birth

A nurse is assessing the bowel sounds of a client with abdominal pain. The nurse would describe the client's bowel sounds as hypoactive:

if sounds occur after a long interval.

A nurse is assessing the preoperative checklist of a client. Which observation listed in the preoperative checklist should the nurse verify?

if the client has urinated properly

A client reports feeling "different" than earlier in the day. When would the nurse anticipate assessing vital signs?

immediately

When the nurse considers the Nursing Process, the word "identify" is to "recognize" as the word "do" is to:

implement

The nurse teaches a patient to use visualization to cope with chronic pain. This action reflects which step of the Nursing Process?

implementation

A nurse is caring for a client with primary constipation. Which factor is responsible for primary constipation?

inadequate intake of liquid

The nurse is assessing residents at a summer picnic at the nursing facility. The nurse expresses concern as a result of the high heat and humidity of the day. Although the facility is offering the residents plenty of fluids for fluid maintenance, what is the nurse most concerned about?

insensible fluid loss

The nurse is working in an acute care setting and performs primary, secondary, and tertiary prevention Which activity performed by the nurse is classified as tertiary prevention?

instructing a client how to use crutches

Strategies to include in a teaching plan for an adult who has repeatedly not followed the written discharge instructions would include which information source?

instructional videos

When the nurse administers a drug that has PRN after the order, the nurse functions:

interdependently

Which is being communicated when the nurse leans forward during a patient interview?

interest

The client is a disabled veteran with bilateral above the knee amputations (AKA). The client frequently has tender, erythemic areas along bilateral incision lines. Which type of facility will provide appropriate care for this client?

intermediate

The nurse is collecting subjective data associated with a patient's anxiety. Which assessment method should be used to collect this information?

interviewing

Which route is inappropriate for a topical medication?

intradermal

A nursing instructor is teaching her class about burns. The instructor relates the following scenario: A nurse is caring for a severely burned client who now has elevated hematocrit and blood cell counts. What consequences should the nurse expect in this client?

kidney stones and blood clots

A physician uses sutures during the surgery on a client at a health care facility. What are sutures?

knotted ties that hold an incision together

The nurse and the patient are conversing face to face. What communication technique is being demonstrated?

linguistic

A patient is admitted to the Emergency Department with difficulty breathing. Which patient response identified by the nurse causes the most concern?

low pulse oximetry

A patient spikes a fever during the first postoperative day after major abdominal surgery. The nurse suspects that the fever indicates an infection. Which site does the nurse conclude most likely is the source of the infection?

lungs

During the physical assessment of a client, the nurse observes flat, round, colored, nonpalpable areas on the face. How should the nurse document this finding?

macules

Following treatment in an inpatient setting, a client has recovered from cellulitis. The nurse recognizes that the client's recovery is partially attributable to the restoration of the client's biologic defense mechanisms. What is an example of a mechanical defense mechanism?

maintenance of intact skin surfaces

A nurse is caring for a patient who is expending energy that is greater than the patient's caloric intake. Which human response will occur?

malnutrition

The nurse has delegated to the unlicensed assistive personnel (UAP) the application of antiembolism stockings to a client who had an endarterectomy earlier in the day. Which UAP action requires the nurse to immediately intervene?

massages legs prior to application

An older adult is admitted to the hospital for multiple health problems. Assessment reveals that the patient has no teeth and is having difficulty eating. Which diet should the nurse encourage the primary health-care provider to order for this patient?

mechanical soft

The nurse is performing a comprehensive assessment of functional capability on a client that lives in a certified nursing home. What federally mandated process is the nurse completing?

minimum data set (MDS)

A nurse is caring for a client whose fractured ankle is in a cast. The client needs crutches to ambulate. What would help prepare this client for ambulation?

modified hand push-ups

A nurse is planning teaching about weight-reduction strategies to an obese patient. Which should the nurse assess first before implementing the teaching plan?

motivation

A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital signs. Which data collected can be classified as subjective data?

nausea

The nurse is concerned about a patient's ability to withstand exposure to pathogens. What blood component should the nurse monitor?

neutrophils

A nurse is orienting a newly admitted patient to the hospital. Which is most important for the nurse to teach the patient how to do?

notify the nurse when help is needed.

While covering a colleague's lunch break, a nurse on an orthopedic unit has responded to a client's call light. The client has requested assistance in transferring from the bed to the bathroom. The nurse has not previously provided care for this client and is unsure of the client's current activity orders. The client's current level of activity can be most easily verified by consulting what written source?

nursing kardex

Which factor places a patient at the greatest risk for postoperative nausea and vomiting after receiving general anesthesia?

obesity

A nurse is assessing a postoperative patient. Which patient response identified by the nurse indicates altered renal perfusion?

oliguria

A patient with flatulence is concerned about the production of unpleasant odors. Which should the nurse encourage the patient to avoid? Select all that apply.

onions & asparagus & eggs

A nurse is caring for a client with pseudoconstipation. What can cause pseudoconstipation in a client?

overuse of suppositories

A nurse plans to take a patient's radial pulse. Which method of examination should be used by the nurse?

palpation

A comatose client is being treated in the intensive care unit of a health care facility. What exercises should the nurse assist this client to perform in order to maintain the muscle tone and flexibility of the client's joints?

passive exercise

Licensure of Registered Professional Nurses is required primarily to protect:

patients

When brushing a patient's hair, the nurse notes white oval particles attached to the hair behind the ears. The nurse should assess the patient further for signs of:

pediculosis

A nurse is caring for a client with an amputated limb. The client tells the nurse that he has a burning sensation in his amputated limb. How should the nurse document this pain?

phantom pain

Determining what nursing actions will be employed occurs in which step of the Nursing Process?

planning

A nurse in the clinic must obtain the vital signs of each patient via an electronic thermometer before patients are assessed by the primary health-care provider. Which patient characteristics indicate that the nurse should take the patient's temperature via the rectal, rather than the oral, route? Select all that apply.

presence of confusion & mouth breather

A nurse is caring for a client who has a stage IV pressure ulcer. What is a characteristic of this type of ulcer?

presence of deeply ulcerated tissue exposing muscles and bones

A nurse is applying a pneumatic compression device to a client. What is the purpose of a pneumatic compression device?

promotes circulation of venous blood

A nurse identifies that the patient has overflow incontinence. Which factor contributes to this clinical manifestation?

prostate enlargement

A nurse reviews the results of a patient's urinalysis. Which constituent found in urine indicates the presence of an abnormality?

protein

A nurse identifies that a vegetarian understands the importance of eating kidney beans when the patient indicates that they are essential because they contain which nutrient?

proteins

When caring for a diabetic client, the nurse notes that the client learns better when he practices the self-administration of the insulin injection by himself. In which learning domain does this client's learning style fall?

psychomotor domain

The occupational nurse is caring for a construction worker employee who stepped on a nail. The nail penetrated the sole of the boot, and injured the worker's foot. What type of injury does the nurse anticipate?

puncture

Understanding cultural differences in health care is important because it will help the nurse to understand the manner in which people decide on obtaining treatments and medical care. In independent cultures an individual will

put himself first.

A nurse is caring for a client with insomnia. The nurse is explaining the importance of sleep to the client. Which role is sleep supposed to play?

reduce fatigue

During discharge teaching with a client who has been treated for a hernia, the nurse has discussed the benefits of a regular regime of physical exercise. What benefits of regular exercise should the nurse cite? (Select all that apply.)

reduced blood pressure & decreased low-density blood lipids & improved bowel function & reduced blood glucose levels

A nurse is assisting a physician who is using the sharp debridement technique at the bedside of a client at a health care facility. What is the purpose of sharp debridement?

removes necrotic tissue from healthy area of a wound

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

reporting trends that suggest development of complications

The registered nurse (RN) is delegating the task of assisting a post-operative client to the bathroom to the unlicensed assistive personnel (UAP). The nurse witnessed the UAP correctly perform the task on previous occasions, and knows the UAP is competent to perform the task. The nurse has communicated how to get the client out and back into bed, and told the UAP not to allow the client to bear weight on the left leg. The nurse validated that the activity was completed and gave the UAP feedback. Which delegation guideline was omitted by the nurse?

right circumstance

Prior to drug administration the nurse reviews the seven rights, which include right patient, right medication, right time, right dose, right education, right documentation, and what other right?

route

A patient of Latino heritage is prescribed a low-fat diet. The patient tells the nurse, "I am going to have a hard time giving up my favorite family recipes." Which food should the nurse recommend that is low in fat and generally is included in the Latino culture?

salsa

A client experiencing symptoms of cold is referred to the specialist for diagnosis and consultation. Consultation and diagnostic tests are included in which level of the health care system?

secondary care

A nurse is caring for a client who was administered opioid narcotics. The client reports constipation. What is another potential side effect of opioid narcotics?

sedation

The nurse educator would identify a need for further teaching when the student lists the which example as a type of learning?

self-directed

A 60-year-old Italian immigrant presents for an annual physical. He is counseled about diagnostic testing including laboratory testing, colonoscopy, influenza vaccination, and pneumococcal vaccination. His reply is "If it isn't broke, don't try to fix it." When developing a plan of care, the nurse should consider which cultural orientation for this patient?

short term

A patient has a high serum cholesterol level. Which foods should the nurse teach the patient to avoid ? Select all that apply.

shrimp & liver

To be most effective, at which grade reading level should the nurse prepare written educational medical material?

sixth-grade

The client lives in a skilled nursing facility and has had an acute exacerbation of multiple sclerosis symptoms. What type of facility will provide the most appropriate care for this client?

skilled

A nurse is assessing the body mass index of a client when determining his body composition. Which of the following factors contribute to the determination of body composition?

skin thickness

A client who is scheduled for hernioplasty needs clarification regarding the procedure. The nurse calls the physician at the client's insistence. The physician, who is in a bad mood, is overheard telling the client that the nurse does not know anything. Which legal tort has the physician committed?

slander

When a nurse evaluates the effectiveness of patient teaching, which food selections by a patient indicate understanding regarding an abundant source of calcium? Select all that apply.

spinach & yogurt

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to be intact, reddened, and unblanchable. How will the nurse categorize this pressure ulcer?

stage I

nurse is transferring a client with myocardial infarction (MI) to a tertiary care center. What referral information is most important for the nurse to relay to the receiving nurse so the client receives appropriate follow-up care?

summary of treatment started and current client condition

Every person who attended a smoking cessation educational program completed a questionnaire. Which is this type of evaluation called?

survey

The nurse identifies that a patient with a fever has warm skin. An additional adaptation that confirms the defervescence (flush) phase of a fever is:

sweating

The nurse is caring for a client with lower extremity paralysis who has been placed in bilateral leg braces. Which crutch-walking gait will the nurse teach?

swing-through

When measuring a client's pulse rate, the nurse records 125 bpm. How will the nurse document the information in the medical records?

tachycardia

A nurse identifies that an older adult patient may have a problem with excess fluid volume. Which characteristics of the patient's skin support this conclusion?

taut and shiny

Interrelated concepts to the professional nursing role a nurse manager would consider when addressing concerns about the quality of patient education include which factor?

technology

A nurse is assessing a client who has been receiving an infusion of normal saline. Which assessment findings should the nurse prioritize? Select all that apply.

thirst & fever & dry skin & weight gain

The nurse is caring for a client who sustained a severe ankle sprain while playing soccer. Which crutch-walking gait will the nurse teach?

three-point non-weight-bearing

A nurse is performing a physical assessment for a client using the palpation technique. What is one of the purposes of using this technique?

to check the skin temperature and moisture

A nurse is assisting a client in performing prescribed range-of-motion exercises. What is one of the reasons why these exercises are being performed?

to test a client's ability to bear weight

Which client's laboratory data indicates the need to include interventions in the nursing plan of care specifically aimed at cardiac and vascular disease?

total serum cholesterol of 180 mg/dL; HDL 32 mg/100 mg/dL

The nurse is caring for a patient experiencing an allergic reaction to a bee sting who has an order for diphenhydramine (BenaDRYL). The only medication in the patient's medication bin is labeled BenaZEPRIL. The nurse contacts the pharmacy for the correct medication to avoid what type of error?

treatment

A nurse teaches a patient about the prescribed low-fat diet. Which foods selected by the patient indicate that the teaching was understood? Select all that apply.

turkey & scallops & flounder

A patient's urine is cloudy, is amber, and has an unpleasant odor. Which problem may this information indicate that requires the nurse to make a focused assessment?

urinary tract infection

An 82-year-old client is newly admitted to an assistive living facility. Which intervention promotes safety at night for the client?

using a night light in the bathroom

A nurse is assessing a patient who states "I feel cold." Which mechanism that helps regulate body temperature will increase body heat?

vasodilation

A nurse assesses a patient for electrolyte imbalances. Which clinical manifestations indicate that the patient may have a potassium deficiency? Select all that apply.

ventricular dysrhythmias & muscle weakness

A male patient suffered a brain injury from a motor vehicle accident and has no brain activity. The spouse has come up to see the patient every day for the past 2 months. She asks the nurse, "Do you think when he moves his hands he is responding to my voice?" The nurse feels bad because she believes the movements are involuntary, and the prognosis is grim for this patient. She states, "He can hear you, and it appears he did respond to your voice." The nurse is violating which principle of ethics?

veracity

When assessing patients who have difficulty sleeping, the nurse assesses for which common physiological responses to insomnia? Select all that apply.

vertigo & headache & fatigue

Which vitamin should a nurse teach a patient does not require fat in the diet to be absorbed?

vitamin C

A nurse is caring for a client who is a vegan at the health care facility. What must be included in the client's diet?

vitamin D

A nurse is interviewing a newly admitted patient. Which words used by the patient describe data associated with the defervescence phase (fever abatement, flush phase) of a fever? Select all that apply.

warm & sweaty

The nurse is providing afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in hypervolemia status?

weight

A nurse should perform hand hygiene in which circumstance?

whenever hands are visibly soiled

A nurse is caring for a client with acute back pain. When should the nurse assess the client's pain?

whenever the vital signs are measured and documented

What does the nurse identify as a goal for a client with the nursing diagnosis of impaired physical mobility related to a new prosthetic limb?

will take sixteen steps independently by Monday