Old prep u quizzes

A group of clinic nurses are engaged in a staff meeting discussion about culture to improve culturally respectful care being given to the clients. Which statement by one of the nurses indicates the need for further clarification and education?

"All cultures are basically the same, even though the beliefs may be different."

A nurse is discussing neonatal care with a new parent. Which statement by the nurse best describes the value of breastfeeding?

"Breastfeeding provides the neonate with immunity against some bacteria and viruses."

When providing culturally respectful care to a client from a different cultural background, which question is appropriate to begin a pain assessment?

"Can you tell me what you think might be causing your pain?"

The nurse is conducting teaching with a client who has a prescription for a wireless capsule endoscopy. Which statement by the client would indicate to the nurse that the teaching was effective?

"I can go about my daily routine while the camera is passing though my small intestine."

The nurse is administering the first dose of an intravenous infusion of an antibiotic. Which statement made by the client is cause for concern?

"I feel like my back and arms are itching."

The nurse is caring for a hospitalized 3-year-old child. The mother expresses concern, stating, "My child was toilet trained for three months. Since being here, she is no longer toilet trained. I cannot understand this." What appropriate response would the nurse provide to the mother?

"It is not unusual for children to regress when hospitalized; it should be short lived."

The nurse and client are looking at the client's heel pressure injury. The client asks, "Why does my heel look black?" What is the nurse's appropriate response?

"That is necrotic tissue, which must be removed to promote healing."

The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend?

2,500 mL/day

A nurse assessing a client's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which form of oxygen delivery should the nurse use for this client?

Ambu bag

A client is operated on for gallstones. On the postoperative night, the nurse finds that the client is not sleeping and is tossing and turning. When asked about analgesics, the client denies having pain. Which nursing action is most appropriate?

Assessing for nonverbal expressions of pain

Which statement should the nurse convey to the mother of a 3-year-old son who has not achieved urinary continence?

Boys may take longer for daytime continence than girls.

The nurse is providing care to a client who has a serum potassium level of 5.2 mEq/L (5.2 mmol/L). Which findings would the nurse expect to assess? Select all that apply

Cardiac arrythmia Muscle weakness

The nurse is preparing to insert an indwelling urinary catheter into a female client's bladder. The nurse has opened the sterile catheterization tray using sterile technique, donned sterile gloves and has opened all sterile supplies. Arrange the following steps in the correct order.

Clean each labial fold, then the area directly over the meatus. Insert the lubricated catheter into the urethra. Advance the catheter until there is a return of urine. Inflate the balloon with the correct amount of sterile saline. Discard used supplies.

The nurse is reading a medication prescription for a drug that is routinely administered every 12 hours. The prescription does not state the frequency of administration. What is the appropriate nursing action and accompanying rationale that guides the nurse's action?

Contact the health care provider to clarify the prescription. Assumptions cannot be made about medication administration and the nurse must practice within the state's nurse practice act and the organization's policies and procedures concerning medication administration

The nurse is assuming care for a client who is receiving an infusion of packed red blood cells (PRBCs). The PRBCs were hung 4 hours ago, and 100 mL is left to infuse. Which action is most appropriate?

Discontinue the infusion and record the volume left in the blood bag.

The nurse just completed a dressing change and returned the client to a comfortable position. What should the nurse do next?

Document the color, odor, amount, and type of wound drainage.

A nurse is providing oral care to a client with dentures. What action would the nurse perform first?

Don gloves

A family consisting of two parents, one grandparent and three school-age children have immigrated to the United States. The nurse needs to provide medication education to the grandparent, who does not speak the dominant language. Which strategy is best for the nurse to use to convey health information to the grandparent?

Engage the services of a trained interpreter.

A nurse is caring for a female client with an indwelling urinary catheter. Which action should the nurse take into consideration to reduce the client's risk of developing a urinary tract infection (UTI)?

Ensure that the catheter is removed as soon as possible.

Which contains all the components of a valid order?

John Smith, atenolol 50 mg, twice a day, by mouth

The nurse assists the client to the bathroom sink to perform morning care. The nurse observes the client wash his face, arms, abdomen, and legs. The nurse washes the client's back and rectal area and applies soap to the back. The client brushes his teeth and ambulates to a chair in his room with assistance. How will the nurse describe the morning care on the client's chart?

Partial care

The client is preparing to obtain a clean-catch midstream urine specimen. Place in order the steps needed to complete the diagnostic test. Use all options.

Provide instruction to the client. Clean the area surrounding the urinary meatus with the provided cloth. Void a small amount into toilet or bedpan. Void into the provided collection device. Secure the lid on the specimen container. Submit collected specimen to the health care professional.

The nurse is performing a physical assessment on a client in moderate pain. Which findings should the nurse determine is a sympathetic response to the pain? Select all that apply

Pupil dilation Muscle rigidity Increased pulse rate Pallor

A nurse has an order to take the core temperature of a client. At which site would a core body temperature be measured

Rectal

While administering a cleansing enema, the client displays lightheadedness, nausea, and has clammy skin. The nurse would implement which priority action?

Stop the procedure, monitor heart rate and blood pressure

The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. Which action should the nurse take?

Stop the transfusion and notify the health care provider.

The nurse is helping a client walk in the hallway when the client suddenly reaches for the handrail and states, "I feel so weak. I think I am going to pass out." Which initial action by the nurse is appropriate?

Support the client's body against yours and gently slide the client onto the floor

When assessing a client's vital signs, a nursing student has explained to the client each of their next actions prior to assessing the client's temperature, pulse, and blood pressure. However, the nursing student did not announce their intention to assess the client's respiratory rate prior to measuring it. What is the rationale for the nursing student's decision to withhold this information?

The client may alter the rate of respirations if the client is aware that his breaths are being

A nurse is caring for a client with a decreased level of consciousness (LOC). When performing mouth care, what action by the nurse will decrease complications of oral care?

The client should be placed in a side-lying position to prevent aspiration.

An older adult client from a minority culture refuses to eat at the nursing home, stating, "I just do not like the food here." What factor should the staff assess for this problem?

The food served may not be culturally appropriate.

The health care provider writes a prescription for ampicillin 1 gram every 6 hours for a client. What would cause the nurse to question this medication prescription?

The route is missing.

Which factor is related to the highest proportion of falls in long-term care settings?

Toileting More than 42% of falls in an acute care agency were toileting related, often involving getting out of bed or ambulating to the bathroom, slipping from the toilet or commode, or standing to use the urinal. This exceeds the role of other variables, including agitation, polypharmacy and impaired sleep.

The nurse is caring for a client with concerns of urinary incontinence. A review of the client's data collection reveals the client has a history of spinal surgery and states, "I urinate all the time and cannot predict when I will urinate." This data collection would suggest to the nurse that this client is experiencing which type of urinary incontinence?

Total incontinence

After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.

True

The nurse has provided a client with oral medications in a small plastic cup. What is the best nursing action to ensure the rights of safe medication administration are implemented?

Wait with the client until the medications are taken.

Which type of mobility aid would be most appropriate for a client who has poor balance?

a cane with four prongs on the end (quad cane)

The nurse and an unlicensed assistive personnel (UAP) are transferring a client from a bed onto a stretcher. Prior to the move, where should the nurse position the stretcher?

alongside the bed at the same height

A client with chronic kidney disease reports not being able to urinate for the past 24 hours. A bladder scan shows no urine in the bladder. How does the nurse document this data?

anuria

The nurse is assessing a newborn in the nursery. The nurse notes the infant has episodes in which breathing ceased for 20 seconds on 2 occasions. The nurse correctly recognizes this condition as

apnea

The correct progression of steps of the nursing process is:

assessment, diagnosis, planning, implementation, and evaluation

A client 57 years of age is recovering in a hospital following a bilateral mastectomy and breast reconstruction 2 days earlier. Since her surgery, the client has been unwilling to mobilize despite the nurse's education on the benefits of early mobilization following surgery. The nurse would recognize that the client's prolonged immobility creates a risk for:

atelectasis

The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia?

confusion

Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue?

corticosteroids

Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. Initial nursing management includes calling the health care provider and:

covering the wound area with sterile towels moistened with sterile 0.9% saline.

An immigrant lives with relatives in a community with many households from the country of origin. The client is taken to the emergency department following a fall at work and is admitted to the hospital for observation. The nurse is aware that this client is at risk for:

culture shock

A 57-year-old man is suffering from polyuria. What can cause polyuria?

diabetes insipidus

The nurse is caring for a client who was in a motor vehicle accident and has severe cerebral edema. Which fluid does the nurse anticipate infusing?

hypertonic

A nurse drains the bladder of a client by inserting a catheter for 5 minutes. What type of catheter would the nurse use in this instance?

intermittent urethral catheter

Which body fluid is the fluid within the cells, constituting about 70% of the total body water?

intracellular fluid (ICF)

Which organ is the primary site for drug metabolism?

liver

A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which delivery device should the nurse use in order to administer oxygen to the client?

nasal cannula

A nurse is caring for a client who is ambulating for the first time after surgery. Upon standing, the client reports dizziness and faintness. The client's blood pressure is 90/50 mmHg. What is the name for this condition?

orthostatic hypotension

A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client?

platelets

A client's primary care provider has informed the nurse that the client will require thoracentesis. The nurse should suspect that the client has developed which disorder of lung function?

pleural effusion

A client in the emergency department is diagnosed with a myocardial infarction (heart attack). The client describes pain in the left arm and shoulder. What name is given to this type of pain?

referred

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

sedation

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough and a bad odor, and it extends into the muscle. How will the nurse categorize this pressure injury?

stage IV

A client reports to the nurse that after delivering an infant, she loses small amounts of urine each time she sneezes or laughs hard. Which type of incontinence does the nurse anticipate?

stress

A nurse is caring for a client who has an infant age 4 months. The client informs the nurse that she has been experiencing a sudden loss of urine whenever she laughs; this is causing embarrassment to her. Which type of urinary incontinence is this client experiencing?

stress incontinence

Various sounds are heard when the nurse assesses a blood pressure. What does the first sound heard through the stethoscope represent?

systolic pressure

A nurse is assessing a client and suspects an ECF volume excess. Which finding would the nurse identify as being most significant?

weight gain of 0.75 kg in a day