PrepU 17
b
A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care? a. Nurse manager b. Nurse case manager c. Physician d. Insurance company
c
A client has terminal cancer and the primary care provider has ordered a diagnostic imaging test. The client does not want the test performed so the nurse agrees to dialogue with the primary care provider on the client's behalf. The nurse's actions are what type of intervention? a. Surveillance b. Supportive c. Coordinating d. Technical
b
A nurse suspects that the client with Crohn's disease does not understand the medication regimen or diet modifications required to manage the illness. What is the nurse's most appropriate action? a. Ask the gastroenterologist to explain the treatment plan to the client and family again. b. Ask the client to verbalize the medication regimen and diet modifications required. c. Ask the nutritionist to give the client strict meal plans to follow. d. Refer the client to available community resources and support groups
a
After learning about a client's limited financial resources and limited insurance benefits, the home care nurse modifies nursing interventions related to a client's care instructions. The nurse modifies the plan of care based upon which client variable? a. Psychosocial background b. Developmental stage c. Research findings d. Current standards of care
b
Before implementing any planned intervention, which action should the nurse take first? a. Have the required equipment ready for use. b. Reassess the client to determine whether the action is needed. c. Ask the client whether this is a good time to do the intervention. d. Record the planned intervention in the client's medical record.
a
Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action? a. Revise the care plan to allow the client to ambulate to the bathroom independently. b. Continue assisting the client to the bathroom to ensure the client's safety. c. Consult with the physical therapist to determine the client's ability. d. Instruct the client's family to assist the client to ambulate to the bathroom.
b
The client has a diagnosis of Risk for Injury related to falls. How would the nurse know if the intervention was successful? a. The client calls for assistance to get out of bed. b. The client is free of falls. c. The client is taught safety precautions. d. The client verbalizes risks for injury.
a
The client is in a rehabilitation unit after a traumatic brain injury. In order to facilitate the client's recovery, what would be the nurse's most appropriate intervention? a. Encourage the client to provide as much self-care as possible. b. Perform all care activities for the client to facilitate rest. c. Teach the family to anticipate the client's needs to care for the client. d. Arrange with the nurse case manager for an early discharge.
c
The client reports right knee pain of 6/10 on the pain scale and requests medication. The nurse assesses and flushes the intravenous site. Which type of intervention skill is the nurse using? a. Interpersonal skill b. Intellectual skill c. Technical skill d. Mechanical skill
c
The client tells the nurse, "I think the nurse last night may have given me the wrong medication, but I was afraid to say anything." What is the nurse's most appropriate response? a. "I will report your concerns to the nurse manager." b. "I will discuss your concerns with the night nurse." c. "You should always speak up if you have any questions about your care." d. "You always have the right to refuse any medication or treatment."
a
The nurse caring for a client who is recovering after a motor vehicle accident is planning for the client to begin increasing responsibility for self-care. Which would be the nurse's most appropriate strategy? a. The nurse encourages the client to take a shower instead of receiving a bed bath. b. The nurse tells the client that recovery is progressing too slowly. c. The nurse consults with the physician to plan an early discharge. d. The nurse instructs the family to stop performing tasks for the client.
b
The nurse has assessed a client and determined that the client has abnormal breath sounds and low oxygen saturation level. The nurse is performing what type of nursing intervention? a. Supportive b. Surveillance c. Collaborative d. Maintenance
a
The nurse has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention? a. Assess the client's response to the ambulation. b. Inform the client when ambulation is scheduled next. c. Discuss the client's feelings about the illness. d. Document the client's ambulation.
c
The nurse in a burn intensive care unit (BICU) is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time? a. Providing medication for agitation b. Repositioning to prevent pressure injuries c. Ensuring that the endotracheal tube is secure d. Changing the dressing to prevent infection
c
The surgeon is insisting that a client consent to a hysterectomy. The client refuses to make a decision without the consent of the client's spouse. What is the nurse's best course of action? a. Remind the client that the client is responsible for the client's own health care decisions. b. Ask the client whether the client is afraid that the spouse will be angry. c. Ask the surgeon to wait until the client has had a chance to talk to the spouse. d. Inform the surgeon that the nurse will not sign the informed consent form.
b
A nurse is caring for a postoperative client who reports a pain level of 6 on a scale from 1 to 10. After administering the prescribed pain medication, which intervention should the nurse include in the nursing care plan to monitor and evaluate pain? a. Assess nonpharmacologic modalities used to reduce pain. b. Implement the ABC guide of pain management. c. Ambulate the client after administration of pain medication. d. Review client goals for comfort.
b
The emergency room (ER) has a strict protocol regarding intramuscular (IM) injection technique. A nurse working in the ER has learned of a new technique to decrease pain with IM injections from the nursing literature and would like to use it. What is the most appropriate way for the nurse to implement the technique? a. Begin using the technique to determine whether it is effective. b. Petition to change the protocol based on the new evidence. c. Ask the ER physician to order IM injections with the new technique. d. Research the protocols at other area emergency rooms.
b
The nurse is assigned a client who had an uneventful colon resection 2 days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change? a. Registered nurse b. Nursing assistant c. A senior nursing student present for clinical d. Licensed practical nurse
c
The nurse is preparing a client for surgery when the client tells the nurse that the client no longer wants to have the surgery. How should the nurse most appropriately respond? a. Review with the client the risks and benefits of surgery. b. Ask the client to discuss the decision with family members. c. Discuss with the client the reasons for declining surgery. d. Notify the physician of the client's refusal.
c
The nursing is caring for several clients. Which intervention can the nurse direct the unlicensed assistive personnel (UAP) to perform? a. Take the vital signs of the client who just returned from surgery. b. Feed a client who is eating for the first time following an ischemic stroke. c. Bathe a client with stable angina who has a continuous IV infusing. d. Assist the client who is ambulating the first time since hip replacement surgery.
b
When caring for a client in the emergency room who has presented with symptoms of a myocardial infarction (MI), the nurse orders laboratory tests and administers medication to the client before the physician has examined the client. For the nurse to be operating within the nurse's scope of practice, what conditions must be present? a. The nurse is using the standards of care for clients with MIs. b. The nurse is operating under standing orders for clients with suspected MIs. c. The nurse is experienced in the needs of clients with MIs. d. The nurse is ordering what the physician usually orders.
c
Which is an independent (nurse-initiated) action? a. Executing physician orders for a catheter b. Meeting with other health care professionals to discuss a client c. Helping to allay a client's fears about surgery d. Administering medication to a client
b
Which nursing action would be most effective in helping a client learn self-care behaviors? a. Check with the client to ensure that personal self-care goals are being met. b. Model self-care behaviors for the client. c. Collect data on the number of self-care activities the client has performed that day. d. Ask client to discuss the client's goals for the day at the start of the shift.
a
The emergency room nurse is performing an initial assessment of a new client who presents with severe dizziness. The client reports a medical history of hypertension, gout, and migraine headaches. Which step should the nurse take first in the comprehensive assessment? a. Perform vital signs and blood glucose level. b. DIscuss the need to change positions slowly, especially when moving from sitting to standing. c. Perform a full review of systems. d. Initiate an intravenous line and administer 500mL of normal saline.
a
The nursing team, consisting of a nurse and experienced unlicensed assistive personnel (UAP), have worked well together for the past year. The nurse instructs the UAP to feed a stable stroke client, assist with dressing a client in preparation for discharge, and take vital signs of a third client in addition to notifying the nurse if the blood pressure becomes low. Which error has the nurse made? a. The nurse failed to communicate clear instructions regarding what constitutes a low blood pressure. b. The nurse delegated tasks to the UAP that are outside the scope of that person's preparation. c. The nurse failed to validate the UAP's knowledge and skill to perform the tasks. d. The nurse delegated too many tasks to the unlicensed assistive personnel.
a
Which nursing action can be categorized as a surveillance or monitoring intervention? a. Auscultating of bilateral lung sounds b. Providing hygiene c. Administering a paracetamol tablet d. Use of therapeutic communication skills
d
While auscultating a client's lung sounds, the nurse notes crackles in the left lower lobe, which were not present at the start of the shift. The nurse is engaged in which type of nursing intervention? a. Educational b. Psychomotor c. Maintenance d. Surveillance
b
A client with diabetes who has been closely following the prescribed plan of care for over a year is being seen at an outpatient facility. The client has not brought a log of daily glucose checks and tells the nurse, "I haven't been doing them regularly." What is the nurse's most therapeutic statement to the client? a. "It is extremely important to your health to strictly follow your plan of care." b. "It seems like you are having difficulty with your care regimen." c. "Should I arrange for a home health nurse to coordinate your care?" d. "Should I instruct your family to do the glucose checks for you?"
a
The nurse is attending a conference on evidence-based practice. Which statement by the nurse indicates further education is needed? a. "I must conduct research to validate the usefulness of my nursing interventions." b. "I can learn about evidence-based practice by reading professional nursing journals." c. "Nursing interventions should be supported by a sound scientific rationale." d. "The Agency for Healthcare Research and Quality is a resource for evidence-based practice."
a
Which type of nursing intervention is oxygen administration and why is it considered to be so? a. A dependent nursing intervention, because oxygen is considered a drug that requires a physician's order b. A collaborative nursing intervention, because it is ordered by the respiratory therapist c. An independent nursing intervention, because nurses have the necessary skill to administer oxygen d. An interdependent intervention, because physicians, nurses, and respiratory therapists have the necessary skill to administer oxygen
b
A client is diagnosed with hypertension, placed on a low-sodium diet, and given smoking cessation literature. The nurse observes the client eating from a fast food restaraunt bag that a family member brought in and the client states, "I don't think I can do this." What is the nurse's first objective when implementing care for this client? a. Explain the effects of a high-salt diet and smoking on blood pressure. b. Identify what barriers the client feels are preventing adherence with the plan. c. Collaborate with other health care professionals about the client's treatment. d. Change the nursing care plan.
