Prep U incorrect Q's quiz #1

The nurse is caring for a client who is postoperative 24 hours from an appendectomy. The client is hesitant to get out of bed. How should the nurse respond?

"Can you describe what you are feeling when you try to move?"

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?" Which is the mostappropriate response by the nurse?

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

A nurse is admitting a client to the unit. Which cultural question is most appropriate?

"What are your dietary needs and preferences?"

A client has undergone foot surgery and will use crutches in the short term. Which teaching point should the nurse provide to the client?

"Your elbows will be slightly bent when you are using your crutches."

In what time period did nursing care as we now know it begin?

18th to 19th century

When assessing an infant's axillary temperature, it will be:

1°F (0.5°C) lower than an oral temperature.

Which scenario is using a prospective payment plan to reimburse for services?

An older adult client is admitted to the hospital and treated for pneumonia. The hospital is reimbursed based on a predetermined fixed price.

A nurse volunteers to serve on the hospital ethics committee. Which action should the nurse expect to take as a member of the ethics committee?

Assist in decision making based on the client's best interests.

Which guideline should the nurse follow when assessing a client's blood pressure using a Doppler ultrasound?

Center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery.

A nurse is caring for a client with orthostatic hypotension. The client is currently not taking any antihypertensive medications. Which action(s) will the nurse take to reduce the client's risk of falls? Select all that apply.

Encourage the client to stand up from a sitting position slowly. Ensure that the client is taking an adequate volume of fluids. Assist the client in applying compression stockings to lower extremities. Ask the client to wait 1 hour after meals to engage in physical activity.

A client who has been lying prone reports shortness of breath and a sensation of choking. Into which position will the nurse place the client?

Fowler's

Assessment of a client's temperature reveals hyperpyrexia. The nurse interprets this as indicating that the client's temperature is most likely:

Greater than 40.5°C

What is a dynamic state in which a person constantly adapts to changes in the internal and external environment?

Health

A client comes to the health center for a routine visit. During the visit, the client tells the nurse, "I'm motivated to do things now to make sure I'm the healthiest I can be." When planning this client's care, the nurse should focus on which area?

Health promotion

Which are stressors that affect the health of the family?

Inadequate childcare services

A client receiving multi-antibiotic treatment is reporting oral thrush and refuses to eat his meals. Which intervention must the nurse perform next?

Inform the physician about this finding.

A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen?

Instruct the client to inhale deeply and then cough.

A nurse reports to the charge nurse that a client medication due at 9 am was omitted. Which principle is the nurse demonstrating?

Integrity

Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen?

It determines whether the client is getting enough oxygen.

The nurse is planning an educational visit with a client. Which must the nurse assess to identify the client's readiness to learn? Select all that apply.

Level of motivation Level of knowledge Willingness to follow the health regimen Physical and psychological abilities to carry out the plan

While providing care to a client, a nurse encounters an ethical problem. The nurse knows the right thing to do, but the facility's policies interfere with the nurse's ability to follow through in doing the right thing. Which condition is the nurse experiencing?

Moral distress

Which statement about neonatal development is accurate?

Neonates may have an infection without fever.

A nurse is assessing the blood pressure of an adult client using the Korotkoff sounds technique to document the measurement. Which phase of Korotkoff sounds will the nurse use to document the systolic blood pressure measurement in the client?

Phase I

The wife of a comatose client wishes to wash the client's hair. Washing the client's hair meets which basic human need?

Physiologic

A nurse is providing care for a client who has had gall bladder surgery. It is the first postoperative day and the client is exhibiting a fever. The nurse suspects what as the most likely cause?

Physiologic stress

When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing

Poor tissue perfusion

A nurse in the emergency department assesses a 3-year-old child with a fractured femur, a hematoma on the back of the head, and multiple 1-cm round scabs and blisters on the upper back. The parents state that their child sustained the injuries by falling out of a high chair. What is the best action for the nurse to take?

Report the suspected child abuse to Child Protective Services.

A client on a surgical unit asks for the nurse's opinion of the surgeon. The nurse says that the surgeon is rude and that the surgeon's clients always end up with infections. The nurse is at risk of being accused of which?

Slander

A nurse, while off-duty, tells the physiotherapist that a client who was admitted to the nursing unit contracted AIDS due to exposure to sex workers at the age of 18. The client discovers that the nurse has revealed the information to the physiotherapist. With what legal action could the nurse be charged?

Slander

Parents raising two school-aged children incorporate their religious beliefs into the family's daily life. The family's beliefs regarding religion include dietary considerations, worship practices, attitudes, and values. This is an example of which function of the family?

Socialization

When analyzing an ethical dilemma according to the ethical framework, what is most important for the nurse to take into consideration?

Standards of conduct

Which model is most useful in examining the cause of disease in an individual, based upon external factors?

The Agent-Host-Environment Model

Which activity performed by an older adult client would make the client's family suspicious of the onset of dementia?

The client is an accountant and has had three episodes of bookkeeping errors.

A nurse takes a client's pulse oximetry reading and finds that it is normal. What does this finding indicate?

The client's available hemoglobin is adequately saturated with oxygen.

What factors must the nurse consider when creating a holistic plan of care? (Select all that apply.)

The client's developmental life stage The client's emotional context The client's physiologic health condition

Which best exemplifies malpractice?

The nurse administers amoxicillin to a client with known allergies to penicillin. The client has a seizure with resulting respiratory arrest.

Legal safeguards are in place in the nursing practice to protect the nurse from exposure to legal risks as well as to protect the client from harm. What is an example(s) of legal safeguards for the nurse? Select all that apply.

The nurse confirms informed consent was give by the client to perform a procedure. The nurse educates the client about what to expect during the hospital stay. The nurse documents all client care in a timely manner.

The nurse is performing an arterial blood gas sampling on a client at 10:45. The nurse educator intervenes if which action is taken by the nurse?

The nurse performs the Allen test after blood sample is taken.

When providing nursing care to the elderly, it is most important to provide comfort due to which of the following changes?

Thermoregulation

A nurse is assisting in the transfer of a client with a diagnosis of Alzheimer's disease to a stretcher. The client experiences frequent periods of agitation and is unable to follow cues or directions. Which device would be the best choice for transferring this client?

Transfer chair

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

During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting?

Vesicular

The nurse auscultates the lungs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding does the nurse expect to document?

Wheezing

The nurse should use the bell of the stethoscope during auscultation of:

a client's heart murmur.

A nurse is considering relocating to another state to practice nursing. Which is the mostappropriate action by the nurse to ensure ability to practice in the new state?

applying for a reciprocal license in the new state

Which pulse site is generally used in emergency situations?

carotid

The client is an employee on the medical unit at the local children's hospital. The nurse is an occupational health nurse educating the client on various routes of exposure. The nurse knows that as a hospital employee, the client is most susceptible to infection by what mode of transmission?

contact

The nurse is caring for a pediatric client with whooping cough. Which precautions will the nurse begin?

droplet

A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client?

flow meter

The nurse has received the arterial blood gas (ABG) results. The ABG was drawn on a client who has been receiving oxygen via partial rebreather mask. Which assessment findings should the nurse act upon after reviewing the ABG? Select all that apply.

headache sore throat fatigue

Nurses are socialized into the:

healthcare culture.

An older adult client is reporting dry, itching skin. The nurse should assess:

how often the client is bathing.

A nurse identifies a client's health care needs and devises a plan of care to meet those needs. Which guideline is being followed in this case?

nursing process

A nurse is preparing to turn a client who is unable to mobilize independently. Which action bestensures the safety of both the client and the nurse?

positioning a friction-reducing sheet under the client to facilitate movemen

Upon assessment of a client with myasthenia gravis, the nurse observes drooping of the upper eyelids. This finding is known as:

ptosis.

A nurse has explained her intention to conduct a Weber test and a Rinne test. Which pieces of equipment will the nurse require?

tuning fork

What is the term for the beliefs held by the individual about what matters?

values

A nurse is assessing a family with adolescents. The family consists of a father, mother, a 13-year-old son, a 14-year-old son from a previous marriage, and a 16-year-old daughter. Which statement by the parents would lead the nurse to suspect a potential risk factor for altered health with this family?

"Our 16-year-old just seems to butt heads with us at every turn."

Which statements made by a nurse would indicate to a nurse manager that the nurse requires further training? Select all that apply.

-"If I make a mistake, I will not tell anyone." -"I will have the supervisor fill out the incident report when I make an error."

Which are characteristics of chronic conditions? (Select all that apply.)

-Are rarely curable -Require lifelong management -Have a prolonged course

The nurse is examining the client's skin to determine whether the delivery of oxygenated blood is sufficient. Which body area(s) will the nurse assess for color change? Select all that apply.

-Nail beds -Tongue -Lips

Nurses in various health care settings provide services to prevent the fragmentation of care that is occurring as a health care trend in today's society. What role of the nurse is most important in preventing this effect?

Coordinator of care

A family recently immigrated to a new country. The parent reports that the teenager is showing signs of fear, has vague reports of stomach pain, and feels humiliated by peers because of their culture. What is the priority assessment for the nurse?

Culture 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.

The growth in home health care is largely attributed to which factor?

Early discharge of clients from the hospital setting

A nurse is assessing a family and identifying where the family is in the family life cycle. During this assessment, the nurse applies Duvall's theory. Which theory forms the basis for Duvall's theory?

Erikson's theory of psychosocial development

A parent of a 17-year-old high school student is allowing the child to decide which college the child will attend. When the child requests direction from the parent in making this decision, the parent responds by stating, "You will need to make this decision on your own." What type of value transmission is the parent displaying?

Laissez-faire

The nurse is preparing to assess the peripheral pulse of an adult client. Which action is correct?

Lightly compress the client's radial artery using the first, second, and third fingers.

A nurse is providing care to a client who is feeling lonely and isolated. In an effort to develop a trusting nurse-client relationship, the nurse exhibits a caring attitude, ensures the client's privacy, and spends time with the client to promote therapeutic communication. The nurse is meeting which category of client needs?

Love and belonging

The community environment affects the well-being of the individual and the family. Which is the health responsibility of the family?

Maintain a healthy lifestyle

A nurse needs to measure the blood pressure of a client with an electronic manometer. Which of the following advantages does an electronic manometer provide over an aneroid manometer or mercury manometer?

No stethoscope is required.

Which statement best conveys the relationship between race and ethnicity?

Race denotes physical characteristics, while ethnicity is rooted in a common heritage.

The nurse suspecting that a client has an infected surgical wound should assess for which sign? Select all that apply.

Redness Swelling Pain Exudate

A client is admitted to the facility after fracturing a hip. The client has undergone surgery to repair the fracture and is receiving services to promote healing of the surgical site and regain mobility. Which discussion should the nurse have with a member of the interdisciplinary team member to promote the goal of regaining mobility?

Speak with the physical therapist about exercises to strengthen muscles.

The nurse caring for several clients on a surgical unit notes that one of the clients is Muslim. The nurse decides to remove all pork from the client's meal tray prior to delivering it to the room. What best describes the nurse's action?

Stereotyping

Together the nurse and a client with hypertension set a goal that states that the client will be able to identify foods to avoid on a low-sodium diet. The nurse completes this action as a part of which American Nurses Association Standard of Care?

The RN identifies client outcomes.

What governing body has the authority to revoke or suspend a nurse's license?

The State Board of Nurse Examiners

The nurse is providing care to a client who had orthopedic surgery. The nurse has medicated the client for pain. However, the client reports that the pain is unrelieved. The nurse takes no further action regarding assessment and intervention for the client's pain. The nurse does not notify the surgeon regarding the client's pain. The nurse's failure to take further action represents which element of liability in this case?

Breach of duty

Nurses practicing in a critical care unit must acquire specialized skills and knowledge to provide care to the critically ill client. These nurses can validate this specialty competence through what process?

Certification

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 client's ear canals for cerumen.

the community environment affects the well-being of the individual and the family. Which is the health responsibility of the family?

Maintain a healthy lifestyle

During a home care visit to a home-bound older client, the client's spouse, who is the caregiver, verbalizes anger, fatigue, and sleeplessness. Which recommendations by the nurse would be most effective in relieving caregiver role strain?

Respite care

Which nursing action(s) best demonstrate the ethical principle of autonomy? Select all that apply.

T-he nurse checks to ensure an informed consent document is signed prior to transferring the client for a surgical procedure. -The nurse documents that a client refused a new medication.

A group of nursing students is reviewing the various white blood cells and how they function in infection. The students demonstrate understanding of the information when they identify which cell as important in synthesizing immunoglobulins?

T-lymphocytes

A nurse is assisting client from a bed to a wheelchair. Which nursing action is appropriate?

The nurse uses assistive devices when lifting more than 35 lb (16 kg) of client weight.

The nurse is teaching the parents of an infant with an irregular heartbeat how to check the pulse rate. The infant's pulse is very high and irregular. What will the nurse have to do in order to teach these parents how to monitor their infant's pulse rate?

The parents will have to be taught how to use a stethoscope so that they can listen to and count the infant's apical pulse.

Which is a characteristic of the care-based approach to bioethics?

The promotion of the dignity and respect of clients as people

Nurses complete incident reports as dictated by the agency protocol. What is the primary reason nurses fill out an incident report?

To improve quality of care

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 tribal traditional healerperforming a healing ritual for the client. What action would be the most appropriate by the nurse?

Unless asked to stay, leave the room and return when the healer is finished.

A registered nurse is overseeing the care of several residents of a long-term care facility. Which task would be inappropriate to delegate to unlicensed assistive personnel (UAP)?

Using a tool to remove a contact lens that has adhered to the resident's eye

A nurse is in charge of care for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which guideline is accurate for using transmission-based precautions when caring for this client?

Wear gloves whenever entering the client's room.

The nurse in a free clinic caring for clients uses the Health Belief Model, which is based on three components. What is the main focus for this model?

What people believe to be true about their health

A client tells the nurse that the client does not want to have a painful procedure. By respecting and supporting the client's right to make decisions, the nurse is demonstrating:

advocacy

A home health nurse is visiting a family after the recent death of their matriarch. The nurse observes that the family is dressed in black, all of the mirrors are covered, and that the immediate family is sitting on square wooden boxes instead of chairs. The nurse asks what is happening, and is told, "We are Jewish, and the family is 'Sitting Shiva'." This family is fulfilling which family function?

affective and coping functions

An obese client has developed peripheral edema as a consequence of heart failure, making it very difficult for the student nurse to accurately palpate the client's peripheral pulses. How should the nurse proceed with this assessment?

auscultate the client's apical pulse

The nurse is assessing a client's thorax and lungs. Which finding would indicate the need for further assessment?

auscultation of short, high-pitched popping sounds during inspiration

Which factor is not known to cause false blood pressure readings?

being in a warm environment

A nurse needs to administer a prescribed medication to a client using IV push. In which way is the medication being administered to the client?

bolus administration

A client with chronic obstructive pulmonary disease has been prescribed a bronchodilator to be administered by small-volume nebulizer. The nurse should ensure that the client:

breathes through his or her mouth until all the medication has been inhaled.

The nurse is caring for a client with a surgical wound. Which action by the nurse best reduces the reservoir of infection?

changing the soiled dressing

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse can anticipate that the digoxin will:

decrease the apical pulse.

A nurse is acting inappropriately and has an odor of alcohol. This behavior breaches the principle of:

ethical conduct. (Ethical conduct dictates that a nurse act in a professional, safe, competent manner.)

A nurse is assessing a client for signs and symptoms of infection. What would the nurse expect to asses? Select all that apply.

increased respiratory rate lymph node enlargement fever

A nurse can most accurately assess a client's heart rate and rhythm by which of the following methods?

listen with the stethoscope at the fifth intercostal space left mid-clavicular line

In the role of entrepreneur, the nurse's primary responsibility is:

managing a health-related business.

A client says to the nurse, "Why don't you wear a white cap like nurses do on the soap operas?" This is an ethnocentric statement based on the:

media

A nurse is evaluating a client's orientation after he was brought into the ER following a car accident. What is indicated by "Oriented x3"?

oriented to person, place, and time

A nurse obtains an order for a bed alarm for a confused client. This is an example of which ethical principle?

paternalism -Making a decision for a client who is confused to prevent an injury

A nurse has collected the blood, urine, and stool specimens of a client with meningococcal meningitis. Which precaution should the nurse take when transporting the specimens?

place the specimens into plastic biohazard bags

What would be an example of the nurse practicing fidelity? The nurse:

stays with a client during death as promised.

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which observation can be made by the nurse and athletes by measuring the blood pressure?

the ability of the arteries to stretch

Which care intervention should the nurse anticipate when providing care to a client admitted with a possible diagnosis of tuberculosis (TB)?

wearing a particulate respirator for all care and interaction with this client

A nurse is assessing a new client's level of activity and exercise. What should be addressed with every client?

whether they have a program of regular physical activity

In which order should the following steps for putting the first hand into a sterile glove be performed? 1. Carefully open the inner package. Fold open the top flap, then the bottom and sides. 2. Place the inner package on the work surface with the side labeled "cuff end" closest to the body. 3. With the thumb and forefinger of the nondominant hand, grasp the folded cuff of the glove for the dominant hand, touching only the exposed inside of the glove. 4. Keeping the hands above the waistline, lift and hold the glove up and off the inner package with fingers down. 5. Place the sterile glove package on a clean, dry surface at or above your waist. 6. Carefully insert dominant hand palm up into the glove and pull it on. 7. Open the outside wrapper by carefully peeling the top layer back and remove inner package, handling only the outside of it.

5, 7, 2, 1, 3, 4, 6

Which is an example of an unintentional tort?

A nurse gives the client a medication, and the client has an adverse reaction to it.

The nurse assesses a male client's genitalia and finds that the scrotal contents are asymmetrical. What action does the nurse take?

Ask the client about any unusual genital observations.

The nurse is attempting to assess a client's radial pulse. The pulse is weak, irregular and unable to be counted. What action would the nurse take next?

Assess the apical pulse.

The nurse is caring for a newborn with bluish nails and lips, rapid respirations, sweating, and having difficulty feeding. Which considerations should the nurse use when assessing the blood pressure to screen for potential cardiac problems? Select all that apply.

-Assess blood pressure in lower extremities. -If the diastolic blood pressure continues to "0," document as the systolic pressure over "P" for pulse -Assess blood pressure in upper extremities.

The nurse must weigh a client using a bed scale. Place the following steps in the correct order. Use all options.

-Place a cover over the sling of the bed scale. -Attach the sling to the bed scale. -Balance the scale so that weight reads 0.0. -Roll client back over the sling and onto other side. -Gradually elevate the sling so that the client is lifted up off of the bed. -Note weight reading on the scale.

Place the following nursing interventions in order of priority according to Maslow's hierarchy of basic needs.

-The nurse teaches the client about foods high in fiber. -The nurse teaches the client's daughter how to safely administer the client's insulin. -The nurse assists the client in making a phone call to the client's daughter. -The nurse positions the bed of the Muslim client who is bedfast toward Mecca.

A client is being screened for a parasitic infection and the physician orders stool specimens. When explaining to the client about collecting the specimens, the nurse would inform the client that the specimens will be collected daily for:

3 days

The nurse has completed an assessment and notes that the client's blood pressure is 132/92 mmHg. What is this client's pulse pressure?

40 mmHg

A client informs the nurse about leaving the health care facility because the client is not satisfied with the treatment. The nurse knows that the client's treatment is incomplete and further testing and evaluations are scheduled. Which action by the nurse would be most appropriate to prevent false imprisonment?

Ask the client to sign a release without medical approval.

The nurse takes a client's vital signs and notes a blood pressure of 88/56 mm Hg with a pulse rate of 60 beats/min. Which action should the nurse take first?

Assess the client for dizziness.

The nurse has palpated the client's radial artery and identified a heart rate of 88 beats per minute with an irregular rate. What is the nurse's most appropriate action?

Auscultate the client's apical heart rate.

A client diagnosed with cancer has met with the oncologist and is now weighing whether to undergo chemotherapy or radiation for treatment. This client is demonstrating which ethical principle in making this decision?

Autonomy

Which ethical principle is related to the idea of self-determination?

Autonomy -self-rule, or self-determination

The nurse is conducting assessment on a client with cancer who is undergoing treatments. The client reports having the flu. Which question(s) should be asked? Select all that apply.

"Has any one in the family recently been sick?" "Have you been frequently out in the community?" "Are you taking steroids?"

While a client admitted to the medical-surgical unit is in the radiology department, a visitor claiming to be the client's cousin arrives on the medical-surgical unit and asks the nurse to provide a brief outline of the client's illness. Which response by the nurse would be most appropriate, both legally and professionally?

"I cannot give you that information due to client confidentiality."

A lawyer is describing the litigation process to a nurse named in a malpractice lawsuit. Which statements by the lawyer accurately describe this process? Select all that apply.

"The process of bringing and trying this lawsuit is called litigation." "The opinions of appellate judges are published and become common law." "Common law is based on the principle of stare decisis."

The nurse is interviewing a client to obtain the health history. Which question would the nurse ask first?

"What brings you here today?"