PREP-U for FINAL: NSG 321
The nurse is teaching a client how to manage their post-operative pain through a Patient Controlled Analgesia (PCA) pump. The nurse determines that additional teaching is needed when the client states which of the following?
"I need to take the medication ONLY when my pain is intense"
The nurse is teaching a client with arthritis about taking medications at home. Which client statement indicates that nursing teaching has been effective?
"I will ask my pharmacist about an easy to open lid"
The nurse has entered the room of a client who is postoperative day 1 and finds the client grimacing and guarding her incision. The client refuses the nurse's offer of p.r.n. analgesia and, on discussion, states that this refusal is motivated by his fear of becoming addicted to pain medications. How should the nurse respond to the client's concerns?
"Research has shown that there is very little risk of clients becoming addicted to painkillers after they have surgery."
What is required to manually regulate an IV drip?
A clock Tubing with a roller clamp
What food would go best and be complementary for an order of ferrous sulfate?
A glass of orange juice
The nurse has identified a priority problem on her unit. Which statement is true regarding addressing a priority problem?
A priority problem requires a nursing intervention before another problem is addressed
According to the gate-control theory of pain, which type of fibers influence closing of the gate, stopping impulses?
A-beta fibers
A nurse caring for the skin of clients of different age groups should consider which accurately described condition?
An adolescent's skin ordinarily has enlarged sebaceous glands and increased glandular secretions
A nurse is volunteering in a free community health clinic at the local YMCA. One of the services offered is vehicle restraint checks for children. Which principles apply to infant and child restraints?
Infants should be rear-facing up to the age of 2 years. Booster seats should be used until the child is 4'9" (1.45 m) tall.
The healthcare provider has given and signed an order for a specific client for furosemide, 20 mg once daily, and recorded the specific date and time of the order. What is the appropriate nursing action?
Call the healthcare provider for order clarification The nurse needs clarification regarding the route of administration, so the provider must be contacted. The nurse cannot administer the drug without this information.
Which statement related to the evaluation of outcome attainment for a client is correct?
Collecting data related to outcome attainment requires the nurse to know when to collect the data, based upon established time criteria.
What are all true statements about fat-soluble vitamins and nutrition?
Fat-soluble vitamins are A, D, E, and K. Fat-soluble vitamins must be attached to a protein for transport in the blood. Deficiencies of fat-soluble vitamins can occur with malabsorption syndromes.
Which would be considered significant blood exposures by occupational health?
Hep. B Hep. C HIV
A nurse is performing a head and neck assessment of a client suspected of having leukemia. How would the nurse detect enlarged lymph nodes commonly associated with this disease?
Inspect and palpate the supraclavicular area.
A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety?
Obtain a three-prong grounded plug adapter.
A client has been diagnosed with a recent myocardial infarction. What collaborative problem would be the priority for the nurse to address?
PC: Decreased cardiac output related to cardiac tissue damage
A client with Type II diabetes has come for an annual wellness check-up with the healthcare provider. Which vaccine will the nurse discuss with the client?
Prevnar 13 EXPLANATION: Clients over the age of 65 years old or those who have a compromising chronic health condition should be offered Prevnar 13 ®, which reduces strains of streptococcal pnuemoniae. Other options are not appropriate for the scenario.
The family members of a dying client have asked for the hospital chaplain's help in having a member of the clergy come to the client's bedside to perform the anointing of the sick. What religion would this be?
Roman Catholic
A nurse is using the SMART acronym to plan outcomes for clients in a long-term care facility. Which criteria describe the use of this acronym?
S - specific M - measurable A - attainable R - realistic T - timebound
A nurse needs to withdraw a prescribed medication from an ampule and administer it to a client. Which action should the nurse perform to ensure that all the medication is equally distributed when withdrawing?
Tap the top of the ampule before withdrawing the medicine.
The nurse is inserting a rectal tube to administer a large-volume enema. Which nursing action is performed correctly in this procedure?
Slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult.
The nurse understands that when assessing a client, the primary source of information is the client. However, the nurse identifies that other sources of client information can include which of the following?
The client's support people The client's health record Family members accompanying the client Other health care professionals
An obese client on the unit has demonstrated difficulty healing a large pressure ulcer. The nurse correctly recognizes that this is most likely because of which factor?
adipose tissue is poorly vascularized
A client states that he is pain and requests the ordered pain medication. When entering the client's room, the client is laughing with visitors and does not appear to be in pain. What is the appropriate action by the nurse?
administer the pain medication
At what point should the nurse perform the first of the three checks of medication administration?
as the nurse reaches for the drug package or container
A nurse enters a client's room to perform a tube feeding. Which nursing action should be performed first?
aspirate contents and check pH
On the first postoperative day, the client is assisted to the bathroom. It is important for the nurse to:`
assess for the client's safety
A client is preparing for a fecal occult blood test. What teaching will the nurse provide regarding vitamin C 3 days before testing?
avoid more than 250 mg
A student nurse studying human anatomy knows that a structure of the large intestine is the:
cecum
An appendectomy would be what kind of surgery?
emergency surgery
Who can make the decision to apply restraints to a client?
nurse practitioner or physician
Which reason best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk?
peer pressure
The nurse is performing a physical assessment on an adolescent. What assessment priorities are needed for this age group?`
scoliosis
What is a recommended guideline for caring for dentures?
store dentures in cold water
A school nurse is dealing with an outbreak of pediculosis in an elementary school. Which education points should the nurse prioritize when educating the parents of students who have lice and nits?
the importance of finishing the prescribed treatment
The nurse is preparing to administer prescribed medication to a client who is Native American/First Nations. The nurse enters the room and observes a shaman performing a healing ritual for the client. What action would be the most appropriate by the nurse?
the nurse leaves the room and comes back when the shaman is finished
In what part of an infection is the patient MOST contagious?
the prodromal stage
Upon auscultation of a client's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound?
wheezes
A client is preparing to give a clean-catch specimen. Which instruction will the nurse provide first?
wipe each side of the urinary meatus with a seperate wipe
The patient has asked the nurse to explain her WBC level of 8,000 cells/mm3. The nurse would identify the level of WBCs as
within normal limits
The nurse is taking a history for a pregnant client who has been seen for chronic headaches for 2 years. Today, the client reports a headache that feels different than the normal headaches she has experienced in the past. Which assessment question helps the nurse assess quality of pain?
"Can you describe the pain that you're having?" EXPLANATION: Asking the client to describe the pain establishes quality. Asking the client to rate pain on a 1-10 scale reflects intensity. Asking how long the pain has existed reflects duration. Asking when the pain began reflects onset.
If a doctor is in a rush to get off the unit and says a verbal order for 2mg morphine as needed q4h, what will the nurse's response be?
"Dr. ___, you will need to write an order for this patient because this is not an emergency situation."
A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response?
"I can assist you to the bathroom and back to bed." EXPLANATION: The client can move in bed, and ambulate while carrying the drainage system as long as he or she has orders to do so. The nurse should supervise ambulation to the bathroom and back to bed while the client has the drain inserted, to make sure it stays intact and to monitor for safety.
The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response?
"Is your child breathing at this time?" Explanation: Initial treatment for a victim of suspected poisoning involves maintaining breathing and cardiac function, so the nurse will ask about the child's respiratory status. Definitive treatment depends on the substance, the client's condition, and if the substance is still in the stomach; vomiting should not be induced until more information is gathered. Instructing the parent about leaving the child alone is not therapeutic at this time.
Which statement made by the client, regarding flat patches of brown skin on the face, demonstrates understanding?
"These brown spots are senile lentigines and are common when you get older."
A 70-year-old female client had a cholecystectomy four days ago. The client's daughter tells the nurse, "My mother seems confused today." Which question would be best for the nurse to ask in order to assess the client's orientation?
"What day of the week is it?"
The mother of a school-age child voices concern to the nurse about her 4-year-old son continuing to wet the bed at night. What information should be provided by the nurse?
"While this is distressing it is not completely uncommon, but interventions are not normally introduced until age 6."
A grandmother visits the pediatric clinic with her daughter and 18-month-old granddaughter. The grandmother states, "I told my daughter she needs to get that baby potty trained. She is too old to be messing in her pants." What is the best response the nurse can make?
"You should start potty training at age 2 to 3 years. At 18 months, she will not be ready to be potty trained."
The nurse is preparing to administer Gravol 50 mg intramuscular to a client. What is the order the nurse is expected to follow when using the Z-track technique to administer the drug?
1. Fill the syringe with the prepared drug and then change the needle. 2. Select the ventrogluteal site. 3. Use the side of the hand to pull the tissue laterally about 1 in (2.5 cm). until the tissue is taut. 4. Insert the needle at a 90-degree angle while continuing to hold the tissue laterally. 5. Aspirate for blood return and instill the medication. 6. Withdraw the needle and apply pressure to the site.
The nurse is assessing a client's bladder volume using an ultrasound bladder scanner. Which nursing actions are performed correctly?
1. The nurse gently palpates the client's symphysis pubis. 2. The nurse places a generous amount of ultrasound gel or gel pad midline on the client's abdomen, about 1 to 1.5 in (2.5 to 4 cm) above the symphysis pubis. 3. The nurse aims the scanner head toward the bladder (points the scanner head slightly downward toward the coccyx). 4. The nurse adjusts the scanner head to center the bladder image on the crossbars.
The nurse receives a verbal order from a physician during an emergency situation. What actions should be taken by the nurse?
1. read back the order 2. mark the date and time of the order 3. include V.O. (verbal order) and the physician name on the order
The healthcare provider has ordered a cold ice bag to be applied to the wrist of a client with a sprain. The nurse will assure that the cold application is at what temperature before application?
10 - 18.3 degrees C (50-65 degrees F)
A nurse is caring for a client, age 4 years, who is being treated for osteomyelitis in his left femur. He is on a 28-day course of IV vancomycin to be administered daily at 1300. Today is day 3 of treatment, and the pharmacist asks the nurse to draw a peak vancomycin level. What would be the most appropriate time to draw this blood?
1500
After sedating a client, the nurse assesses that the client is frequently drowsy and drifts off during conversations. What number on the sedation scale would the nurse document for this client?
3 on the 1-4 scale EXPLANATION: The Pasero Opioid-Induced Sedation Scale that can be used to assess respiratory depression is as follows: 1 = awake and alert; no action necessary 2 = occasionally drowsy but easy to arouse; requires no action 3 = frequently drowsy and drifts off to sleep during conversation; decrease the opioid dose 4 = somnolent with minimal or no response to stimuli; discontinue the opioid and consider use of naloxone
During the nursing examination, the nurse notices that the client, an older adult female, becomes very tired, but there are still questions that need to be addressed in order to have data for planning care. Which action would be most appropriate in this situation?
Ask the client if it is okay to interview her husband for the answers to the interview questions.
A client prescribed pain medication around the clock experiences pain one hour before the next dose of the pain medication is due. Which is the most appropriate action by the nurse?
Assess for medication order for breakthrough pain.
The nurse is caring for a client who has experienced significant pain following a surgical procedure. Which nursing interventions are appropriate?
Assess for pain control 30 minutes after administering an analgesic. Consider cultural implications of the perception of pain. Provide pain medication before activity that may increase pain.
The nurse has read in the client's medical record that she has a diagnosis of metabolic syndrome. What assessment finding is consistent with this diagnosis?
BP is 151/92 EXPLANATION: Metabolic syndrome is characterized by obesity, abdominal fat, hypertension, and elevated blood glucose (insulin resistance) and fat levels. Respiratory problems, heart rate, and edema are not components of a diagnosis of metabolic syndrome.
Which action is appropriate when evaluating a client's responses to a plan of care?
Continue the plan of care if more time is needed to achieve the goals/outcomes.
Home health care nurses frequently use the acronym DAME to assess the risk for falling in older adults at home. What do the letters stand for?
D stands for drug and alcohol use A stands for age-related physiologic status M is for medical problems E represents environment
Which actions would the nurse perform when administering a subcutaneous injection correctly?
Grasp and bunch the area surrounding the injection site or spread the skin taut at the site. Inject the needle quickly at an angle of 45 to 90 degrees. After removing the needle, do not massage the area to prevent hematoma formation.
Nurses assess clients who have physiologic responses to pain. Which examples of pain response are physiologic responses?
Increased blood pressure Muscle tension and rigidity Nausea and vomiting
Which nursing diagnosis is a correctly written 3-part nursing diagnosis?
Ineffective Health Maintenance related to lack of motivation as evidenced by client's statement of disinterest in improving health Constipation related to side effects of antidepressants as evidenced by passage of hard, dry stool
Which nursing action is appropriate in the care of a client with an implanted vascular access device?
Maintain patency by routine flushing with a heparinized solution.
Which of the following are parts of the client record that include only the findings of physicians?
Medical history Physical exam Progress notes
The nurse is caring for a 48-year-old male patient with a new colostomy. Which patient goal for Mr. Conner is written correctly?
Mr. Conner will demonstrate proper care of stoma by 29MAR2015.
A client is undergoing conscious sedation for an endoscopy. When the client becomes overly sedated, which medication does the nurse anticipate will be required?
Naloxone Naloxone is a reversal drug, as it is the antagonist for opiates like morphine. The other medications are inappropriate choices.
The nurse preparing to admit a client receiving epidural opioids should make sure that which of the following medications is readily available on the unit?
Narcan EXPLANATION: The nurse should ensure that Narcan is readily available on the unit, as it can reverse the respiratory depressant effects of opioids.
The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss?
Subjective data should be included when documenting.
A client is prescribed an opioid analgesic. The nurse is teaching the client a about the need to avoid ingesting alcohol with the drug to prevent an interaction which would potentiate the effects of the analgesic. The nurse is describing which event?
Synergism Explanation: When one drug potentiates the effect of another drug when taken together, synergism occurs. Antagonism occurs when the effects of one drug are decreased by another drug. Incompatibility occurs when a drug precipitates from solutions, or becomes chemically inactive, if mixed with other medications.Tolerance to a medication occurs when a patient develops a decreased response to the drug, requiring an increased dosage to achieve the therapeutic effects.
What nursing action reflects a step in the care of a Penrose drain that needs to be shortened each day?
The nurse pulls the drain out a short distance using sterile scissors and a twisting motion, then cuts off the end of the drain with sterile scissors.
A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct regarding the filing of a safety event report?
The nurse should record the incident in the client's medical record and fill out a safety event report separately.
What characteristic is important to know for a bunionectomy (removal of bone tissue from the base of the great toe)?
The patient arrives for the procedure and returns home the same day
The nurse is providing education to a client about the role of endogenous opioids in the transmission of pain. Which information about the release of endogenous opioids is most accurate?
They bind to opioid receptor sites throughout the CNS. EXPLANATION: When endogenous opioids are released, they are believed to produce their analgesic effects by binding to specific opioid receptor sites throughout the central nervous system (CNS), blocking the release or production of pain-transmitting substances.
Alex is a 15-year-old diagnosed with acute lymphocytic leukemia (ALL). The nurse draws his morning labs and notes a hematocrit of 28, WBC of 10, platelets 68. Which of the following would the nurse expect that a licensed practitioner would order?
This client is both anemic and thrombocytopenic. Both red blood cells and platelets could be administered in this case
The nurse is teaching a client how to perform pelvic floor muscle exercises (Kegel Exercises). Which teaching will the nurse include?
Tighten the internal muscles used to prevent or interrupt urination
In which position would the surgical nurse place a patient undergoing minimally invasive surgery of the lower abdomen or pelvis?
Trelendenburg position, in which the pt is supine and feet are elevated at a 15-30 degree angle
Which of the following are true regarding safety of the older adult while bathing?
Use of a tub/shower seat may be necessary if balance problems are present. Water temperature should be monitored carefully due to decreased temperature sensation. Use a long-handled shower brush or attachment to help with limited mobility.
A client asks the nurse which vitamins should be taken daily for feelings of fatigue, anxiety, and depression 1 week before menses. Which of the following is the correct response by the nurse?
Vitamin B6
A nurse is evaluating the effectiveness of health promotion teaching related to hygiene at a community workshop. Which statements by the one of the participants requires further teaching to ensure understanding?
WRONG STATEMENTS: "It is important to brush your teeth regularly but flossing is not necessary since it can damage the gums." "Hygiene does not contribute to my well-being so I can choose to not perform hygiene." "Hygiene measures have no affect on skin."
Which question, if asked by the student, would indicate to the faculty that the student has a clear understanding of open-ended questions?
Why did the healthcare provider prescribe this medication for you?
The nurse recognizes common pain syndromes that cause neuropathic pain. Which clients would the nurse place at risk for this type of pain?
a client with postherpetic neuralgia a client with phantom limb pain a client with diabetic neuropathy a client with complex regional pain syndrome
The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be what kind of consistency?
a liquid consistency
According to Shelly and Fish, which of the following is a spiritual need underlying all religious traditions?
a need for meaning and purpose
A pregnant client asks the nurse for information on breastfeeding her baby. What type of nursing diagnosis would the nurse formulate?
a wellness diagnosis
Which client most likely requires special preoperative assessment and treatment as a result of the existing medication regimen?
a woman who takes daily anticoagulants to treat atrial fibrillation EXPLANATION: Anticoagulants present a risk of hemorrhage. This risk supersedes that posed by thyroid supplements, ACE inhibitors, or most NSAIDs.
The nurse is caring for a client who has been repetitively pulled at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail, the healthcare provider orders chemical restraints. Which treatment does the nurse anticipate?
administering of antipsychotic agents
A 2-year-old toddler just underwent a tonsillectomy and adenoidectomy surgery. The postanesthesia care unit (PACU) nurse is checking on him. What is the best course of action regarding the developmental care of this child?
allow the parents to come into the room before the child wakes
A nurse is attempting to complete an admission database. While taking the history, the nurse notices the client appears uncomfortable and slightly tachypneic. What should the nurse do?
allow the pt to set the pace of the interview
People with spina bifida often have issues with what urinary complication?
alterations in urinary elimination
Perioperative phase refers to what time in relation to surgery?
before, during and after
While assessing a 48-year-old client's near vision, the nurse can anticipate the client will state that her vision is:
blurred
A hospital is changing the format for documentation in an attempt to decrease the amount of time the nurses are spending on charting. The new type of charting will require that the nurses document the significant findings as a narrative note, in a shorthand method using well-defined standards of practice. Which of the following best defines this type of charting?
charting by exception
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
The nurse is caring for an 88-year-old male admitted 2 days ago for dehydration. The nurse brings the client his breakfast tray and notes that the client appears to be having difficulty understanding what she is saying to him today. Which nursing action is most appropriate?
check the ears for cerumen
A nursing student is preparing a presentation on client records and documentation. What information should the student include in the presentation?
communication is the primary purpose of client records
The nurse is planning to do a physical assessment on a newly admitted client.The assessment will be a review of systems (ROS). This means the nurse plans to do which of the following?
complete an exam of all body systems
What anesthesia is commonly used for a colonoscopy?
conscious sedation
A newly graduated nurse is unable to determine the significance of data obtained during an assessment. What would be the nurse's most appropriate action?
consult with a more experienced nurse
The nurse knows that as a hospital employee, the client is most susceptible to infection by what mode of transmission if the nurse works at a children's hospital?
contact transmission
A client age 78 years with diabetes needs to have his toenails trimmed. It is important for the nurse to do what?
cut the nails straight across
A nurse observes that a client who underwent knee surgery 2 weeks ago needs progressively larger doses of analgesics to get relief from pain. The nurse interprets this as
dependence
The nurse is preparing to change a client's sterile dressing. Which action by the nurse would increase the risk for infection?
describing each step verbally to the patient during the dressing change nurse should describe to pt BEFORE
The recovery nurse is caring for a surgical client in the PACU. The client's blood pressure is dropping and the heart rate is increasing. The nurse suspects the client is:
developing shock
A nurse is assessing the lungs of a client and auscultates soft, low-pitched sounds over the base of the lungs during inspiration. What would be the nurse's next action?
document normal breath sounds EXPLANATION: Soft, low-pitched, whispering sounds are normal sounds heard over most of the lung fields. Inflammation of the pleura would result in a friction rub. There are no signs of pneumonia, and recommending testing for pneumonia is not in the nurse's scope of practice. Asthma usually results in wheezing.
When performing a dressing change, the home care nurse notes that base of the client's leg wound is red and bleeds easily. Which of the following is the appropriate action by the nurse?
document the findings
While reading a client's history, the nurse notes that a client has a colostomy. When assessing the client, the nurse notes that the output is formed stool. What should the nurse do?
document the output/finding, this is normal
At what time only are verbal orders accepted by the nurse?
during emergency situations
How should the nurse position the head of the bed for a client receiving epidural opioids?
elevated 30 degrees
A nurse is preparing to provide discharge instructions to a postpartum client regarding infant care. Before beginning the education session, the nurse should:
eliminate as many distractions as possible EXPLANATION:
A school nurse is aware of poisoning risks in the adolescent population. Poisoning in this age group is most often related to:
experimentation with drugs and inhalations
Personal protective equipment for use with standard precautions includes which items?
face mask disposable gloves fluid repellent gown eye protection
The nurse is scheduling tests for a client who is experiencing bowel alterations. What is the most logical sequence of tests to ensure an accurate diagnosis?
fecal occult blood test, barium studies, endoscopic examination
A nurse on a medical unit recognizes the need to demonstrate Quality and Safety Education for Nurses (QSEN) competencies in clinical practice. Which action best demonstrates the skills necessary to meet the QSEN competency of safety?
filling out an incident report accurately after a client went missing from the unit
A client reports that he is often unable to retain urine until he locates a toilet because his mobility is decreased. The nurse should recognize the characteristics of what type of incontinence?
functional incontinence functional incontinence when the client is unable to retain urine for some time after getting an urge to void Stress incontinence can result in the loss of small amounts of urine when intra-abdominal pressure rises Urge incontinence is the need to void, perceived frequently with a short-lived ability to sustain control of flow Total incontinence is the loss of urine without any identifiable pattern.
A client comes to the emergency department complaining of a shooting pain in his chest. When assessing the client's pain, which behavioral response would the nurse expect to find?
guarding of the chest area
When educating families on fire safety, it is important to:
have a meeting place outside the home
The nurse notices during an assessment interview that the client cannot stay on focus and jumps from one topic to another. The client also is speaking very rapidly and at time incoherently. What should the nurse suspect is the main cause of this behavior?
high anxiety
A nurse is percussing the thorax of a patient with chronic emphysema. What percussion sound would most likely be assessed?
hyperresonance
A nurse is administering pain medication to an 80-year-old man. What altered drug response might be expected due to the client's age?
increased possibility of drug toxicity due to higher drug plasma concentrations
A nurse is formulating a nursing plan of care for a client based on assessment data. When writing this plan, which would be most important for the nurse to include?
nursing interventions
The nurse has entered a client's room to empty the client's urine collection bag at the end of a busy shift. The nurse realizes that the client's urine output is 75 mL over the past 8 hours. The nurse would recognize that the client is experiencing:
oliguria Oliguria is a significant decrease in urine production Anuria is an absence or near-absence of urine output Nocturia is nighttime awakening to void Polyuria is greatly increased urine production.
A nurse is caring for a 48-year-old man with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, three times per day, leads to expedited discharge. What type of evaluation best describes what the researchers are examining?
outcome evaluation EXPLANATION: An outcome evaluation determines the extent to which a client's behavioral response to a nursing intervention reflects the outcome criteria.
When an older adult client is brought to the recovery room and presents with irregular, loud respirations, the nurse determines that this most likely a result of:
partial airway obstruction
A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which of the following measures would be a high priority recommendation for this client?
place a client with a bed that has an alarm
A school nurse is preparing an education session on safety for parents of school-age children. What would be an appropriate topic for this age group?
providing drug, alcohol and sexuality education
A client who has been harassed at her place of work tells the nurse, "Every time I think of my job, I get a debilitating headache and have to go lie down to make the pain go away." Which nursing intervention will the nurse perform to practice according to the Gate Control Theory?
providing temple massage when head hurts
The nurse is providing discharge teaching to the family of an older adult client. Which teaching will the nurse include to decrease the risk for electric shock?
refrain from using extension cords
The nurse has worn a gown and gloves while caring for a client in contact isolation. How will the nurse appropriately remove this personal protective equipment (PPE)?
remove gloves, remove gown, wash hands
A client who was a victim of domestic violence for many 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 debilitating headache and have to go lie down to make the pain go away." Which nursing intervention reflects practice according to the Endogenous Opioid Theory?
requesting healthcare provider to order opioid medication
A nurse is caring for an infant who is postoperative following cardiac surgery. What is the most common postoperative complication found in this age group?
respiratory complications
A 9-month-old baby is scheduled for heart surgery. When preparing this patient for surgery, the nurse should consider which surgical risk associated with infants?
risk for hypothermia and hypothermia
Allen is an 82-year-old retiree who recently relocated to senior apartments. The apartments are not affiliated with any religious beliefs. Allen was raised in the Roman Catholic church and has attended mass every Sunday since childhood. He has not attended mass for 3 weeks. What best describes Allen's situation?
separation from spiritual ties
A nurse is at the end of a busy shift on a medical-surgical unit. The nurse enters a room to empty the client's urinary catheter and the client says, "I feel like you ignored me today." In response to the statement, the nurse should:
sit at the bedside and allow the patient to explain the statement
The nurse is caring for a client who has had back pain for 2 years, following a fall from a ladder. How does the nurse going off-shift report this kind of pain to the oncoming nurse?
somatic and chronic pain EXPLANATION: Somatic pain develops from injury to structures such as muscles, tendons, and joints. Chronic pain is discomfort that lasts longer than 6 months.
The nursing supervisor is evaluating how many clients each of the department nurses has been assigned for the shift. This type of evaluation would be considered:
structure
How can the nurse researcher obtain information from a client record?
study the client records
Nurse Mayweather is auscultating lung sounds. She notes crackles in the LLL which were not present at the start of the shift. Nurse Mayweather is engaged in which type of nursing intervention?
surveillance intervention
A nurse is caring for a client in a wound care clinic. The client has a wound on the right heel that is 2 cm × 4 cm. The wound is a maroon color and looks like a blood-filled blister. Which stage should the nurse document for this wound?
suspected deep tissue injury
What is the preferred site to use for a nitroglycerin transdermal patch?
the chest
A new nurse observes a priest visiting the clients every Saturday afternoon and praying with them. This activity supports which of the nursing outcomes?
the client uses a type of spiritual experience that provides her comfort
The nurse is caring for a client who has a fungal infection in the groin. The client reports feeling sore and itchy. Upon assessment, the nurse notes a cluster of vesicles that are scaly and cracked. What tinea condition does the nurse anticipate?
tinea cruris
The nurse monitors the urine output of a postoperative client. The results of this assessment allow the nurse to monitor for signs of what complication?
tissue perfusion
true or false: A Penrose drain typically exits a client's skin through a stab wound created by the surgeon
true
Which nursing intervention is most likely to prevent respiratory complications such as pneumonia and atelectasis in a postoperative client?
use of incentive spirometry (would not be adequate fluid and nutrition)
After being informed that his wife only has a few hours to live, the nurse hears the husband say; "If you take my wife now. I will never pray to you!" What should be the nurse's reply?
use silence and allow the husband to share his emotions
Which of the following modifications to bathing should be implemented for a client who is incontinent?
use special perineal cleansers and moisture barriers
A nurse is caring for a client who complains of an aching pain in the abdomen. The nurse also noted that the client is guarding the area. What kind of pain is the client experiencing?
visceral pain The client is experiencing visceral pain, which is poorly localized and originates in body organs in the thorax, cranium, and abdomen. A reflex contraction or spasm of the abdominal wall, called guarding, may occur as a protective mechanism to prevent additional trauma to underlying structures. In cutaneous pain, the discomfort originates at the skin level, and is a commonly experienced sensation resulting from some form of trauma. Somatic pain develops from injury to structures such as muscles, tendons, and joints. Neuropathic pain is experienced days, weeks, or even months after the source of the pain has been treated and resolved.
