The Point Study Guide

A client has a nursing diagnosis of Risk for injury related to adverse effects of potassium-wasting diuretics. What is a correctly written client outcome for this nursing diagnosis?

"Before discharge, the client correctly identifies three potassium-rich food sources."

The employer of a client on a psychiatric unit calls the nursing station inquiring about the client's progress. The nurse doesn't know if consent has been given by the client to allow the staff to give information to callers on the phone. Which response by the nurse would be best?

"I can't confirm whether your employee is a client here."

A client is admitted to the inpatient unit of a mental health center with a diagnosis of paranoid schizophrenia. He's shouting that the government of France is trying to assassinate him. Which response by the nurse would be most appropriate?

"I don't think this is true. You are safe here, but you must feel frightened by this."

A nurse is teaching a postpartum client about breast-feeding. Which statement best indicates that the client knows how to prevent breast engorgement?

"I'll breast-feed every 2 to 3 hours."

A client develops hepatic encephalopathy 1 week after portal caval shunt surgery. Her physician prescribes neomycin, 4 g by mouth daily in four divided doses. Her husband asks how neomycin decreases his wife's serum ammonia concentration. How should the nurse respond?

"It decreases the number of ammonia-producing bacteria in the GI tract."

The nurse is providing teaching for a client with hepatitis A. Which statement by the client indicates the need to reinforce the teaching?

"It is all right to French kiss my partner."

A nurse is caring for a client with otosclerosis who's scheduled for stapedectomy. The client asks the nurse when his hearing will improve. Which response by the nurse is most appropriate?

"It might take as long as 6 weeks for your hearing to improve."

A toddler is in the hospital. Which response to the parents, who are concerned about the seriousness of the child's illness, would be the most appropriate?

"It must be difficult for you when your child is ill and hospitalized."

A client with coronary artery disease reports intermittent chest pain that occurs with exertion. The physician prescribes sublingual nitroglycerin. When teaching the client about nitroglycerin administration, the nurse should include which instruction?

"Take nitroglycerin with caution because it may cause dizziness."

A nurse is providing information to a client about the ear canal. What information would the nurse include?

"The ear canal of an adult slants downward."

The nurse receives a call from the laboratory with some lab values. Which lab value represents the highest priority for the nurse?

Calcium level of 32 milligrams/dl

A nurse is caring for a client who's undergoing a cystoscopy to diagnose bladder cancer. After the test, the client returns to his room. Which signs should alert the nurse to a potential complication?

Chills and tachycardia

When inspecting a client's skin, the nurse finds a vesicle on the client's arm. How will the nurse document his findings about this client's vesicle?

Circumscribed, elevated, and filled with serous fluid

A client is prescribed acetaminophen by mouth every 4 hours as needed for headache. Which factor in the client's medical history would cause the nurse to question this order?

Cirrhosis

An infant boy has just had surgery to repair a cleft lip. Which nursing intervention is most important during the immediate postoperative period?

Clean the suture line carefully with sterile solution after every feeding

A nurse is caring for a client who relates well to others but displays these behaviors: failure to adhere to tasks, failure to learn new skills, unwillingness to set goals, and inaccurate follow-through of instruction. Which nursing diagnosis is most appropriate for this client?

Deficient knowledge related to lack of motivation

A nurse is evaluating a client with possible Cushing syndrome. In a client with Cushing syndrome, what assessment finding would the nurse expect?

Deposits of adipose tissue in the trunk and dorsocervical area

When developing a therapeutic relationship with a client, when should the nurse begin preparing the client for termination of the relationship?

During the first meeting

A 3-year-old boy is having a third and final surgery to repair severe hypospadias. He returns from surgery with dextrose 5% in water (D5W)infusing I.V. at 40 mL/hour, an indwelling urinary catheter in place, and an order for diet as tolerated and pain medication as needed. Which action would be best for the nurse to perform in order to prevent separation of the incision?

Elevate the scrotal sac.

A nurse is caring for a client who's receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension?

Ensure adequate hydration before the anesthetic is administered.

A nurse collecting data on a pregnant woman in a clinic learns that the woman smokes a pack of cigarettes per day. What is the first step the nurse should take to help the woman stop smoking?

Evaluate the client's readiness to stop.

An elderly client tells the nurse that he doesn't want to take a bath. Which action by the nurse is most appropriate?

Explaining why a bath is important to overall health, and telling the client that she'll return in 30 minutes to help him

The nurse is preparing to provide contraceptive counseling for a young client. What should the nurse plan to do first?

Explore her own personal beliefs and feelings about contraception.

When attempting to dislodge a foreign object from an infant's airway, the rescuer should initiate five back blows followed by what intervention?

Five chest thrusts

The nursing instructor is demonstrating a head-to-toe assessment. Which plane would the instructor use to divide the body longitudinally into anterior and posterior regions?

Frontal plane

The nurse is caring for a 40-year-old client admitted with an acute myocardial infarction. Which behavior by the client indicates adult cognitive development?

Generates new levels of awareness

A nurse is teaching a client how to irrigate his colostomy. Which action indicates that the client needs more teaching?

Hanging the irrigation bag 12 to 18 inches (30 to 45 cm) above the stoma

A nurse is explaining how to measure blood pressure in a client who has lymphedema in both arms and requires blood pressure measurement using a thigh cuff. In reference to the client's baseline arm blood pressure, what information would the nurse expect to find when utilizing the thigh?

Higher systolic blood pressure reading

A client with a history of heart failure is admitted to the telemetry unit. Which parameter should the nurse closely monitor in evaluating the client's response to a bolus dose of I.V. furosemide?

Hourly intake and output

A client who's at 32 weeks' gestation is diagnosed with preeclampsia. Which findings are consistent with mild preeclampsia?

Hypertension, edema, and proteinuria.

The nursing instructor asks the nursing student to select a type of solution, when administered intravenously (I.V.), would cause a shift of fluid from the interstitial space to the intravascular space. Which solution will the student choose?

Hypertonic

A nurse is teaching a client with pernicious anemia who requires vitamin B12 replacement therapy. Which statement indicates that the client understand the treatment program?

I'll need an injection of vitamin B12 every month for life.

The nurse is monitoring the effectiveness of a client's drug therapy. The health care practitioner orders a trough level. When will the nurse obtain the blood sample to measure the trough drug level?

Immediately before administering the next dose.

The nurse is performing vital signs on a client. What should the nurse do to avoid recording an erroneously low systolic blood pressure because of failure to recognize an auscultatory gap?

Inflate the cuff at least another 30 mm Hg after the radial pulse becomes impalpable.

A female client who recently had a colostomy expresses concerns about her sexual relationship with her husband. Which intervention is the most appropriate?

Inviting a client with a similar experience to speak with the client

A nurse is performing a focused cardiac assessment. In which position would the nurse ask the client to assume, so he or she can auscultate for heart sounds more easily?

Leaning forward

A 76-year-old client with no debilitating conditions belongs to which geriatric population?

Middle-old

When assessing if a procedural risk to a client is justified, the ethical principle underlying the dilemma is known as which of the following?

Nonmaleficence

A nurse discovers that a stat dose of potassium chloride that was prescribed by the physician was never administered. Which action should the nurse take?

Notify the charge nurse so she can notify the physician of the missed dose.

A client in a long-term care facility has signed a form stating that he does not want to be resuscitated. He develops an upper respiratory infection that progresses to pneumonia. His health rapidly deteriorates, and he is no longer competent. During morning rounds, the nurse finds this client without vital signs. What should the nurse do next?

Notify the physician that the client has no vital signs.

A client is scheduled for surgery at 8 a.m. While completing the preoperative checklist, the nurse sees that the surgical consent form hasn't been signed. It's time to administer the preoperative analgesic. Which nursing action takes the highest priority in this situation?

Notifying the surgeon that the consent form hasn't been signed

A nurse is providing postoperative care for a client who has had spinal anesthesia. The nurse should place the client in which position?

On his left side in Sims position

A nurse is administering preoperative sedatives to a client who's preparing to undergo an aortobifemoral bypass. After administering the preoperative sedatives, what should the nurse do?

Place the bed in a low position with the side rails up.

A primipara client at 32 weeks' gestation comes to the hospital complaining of vaginal bleeding. She has soaked one peri-pad. She has no pain or cramps. What's one possible cause of the vaginal bleeding?

Placenta previa

A nurse is collecting baseline data on a client's pressure ulcer risk. Which finding is a key evaluation parameter?

Poor nutritional status.

The nurse is examining a client with suspected peritonitis. What nursing intervention does the nurse use to elicit rebound tenderness?

Press the affected area firmly with one hand, release pressure quickly, and note any tenderness on release

A nurse is caring for a client who was admitted with a diagnosis of multiple myeloma. Which nursing intervention is most appropriate for this client?

Prevent bone injury.

The nurse distinguishes that which assessment data will most influence a client in crisis?

Previous coping skills

A 4-year-old is having a sickle cell crisis. What initial nursing intervention should the nurse perform?

Provide oral and I.V. fluids.

The nurse is caring for a group of clients. Which of the following activities by the nurse is the best example of the nurse as an interdisciplinary team member?

Recommending a physical therapy consult because of altered mobility

Before clients can learn, they must believe that they need to learn the information. The nurse recognizes that this is an example of which learning principle?

Relevance

A client who suffered a stroke has a nursing diagnosis of Ineffective airway clearance. The goal of care for this client is to mobilize pulmonary secretions. Which intervention would help meet this goal?

Repositioning the client every 2 hours

After her shift, a nurse remembers that she failed to document a medication that she administered. What should the nurse do?

Return to the client care area and document the medication as given.

A client with advanced cancer has been receiving chemotherapy and is experiencing stomatitis. To promote comfort and nutrition while the client's mouth is sore, what should the nurse plan to speak with the client's family about?

Rinsing the client's mouth with diluted hydrogen peroxide every 2 hours

An inpatient psychiatric client suddenly becomes loud and visibly anxious. What's the best action for the nurse to take?

Say to the client, "Let's go talk in your room."

An 18-month-old's mother complains that the child seems tired and fussy even though she naps twice per day and sleeps through the night. The nurse notes that the child is pale and clings to her mother during the health history and evaluation. Which finding should lead the nurse to suspect iron-deficiency anemia?

She drinks 40 to 48 oz of pasteurized cow's milk daily.

A 49-year-old client with acute respiratory distress watches everything the staff does and demands full explanations of all procedures and medications. The nurse identifies which assessment as evidence that the client has achieved an increased level of psychological comfort?

Sleeping undisturbed for 3 hours

A nurse is caring for a client with glaucoma who has gradually lost his eyesight. When assisting the client with ambulation, where should the nurse walk?

Slightly in front of the client, offering an elbow for the client to hold.

Which nursing diagnosis is correctly worded?

Social isolation related to laryngectomy evidenced by inability to speak

When reviewing a client's file, the nurse reviews the following medication order "Vitamin K 10 mg intramuscular (I.M.) daily × 3 days?" The nurse recognizes this as which type of order?

Standard written order

After assessment of vital signs and application of an external monitor, which nursing intervention is a priority for a client with suspected placenta previa?

Start I.V. catheters and obtaining blood work.

A parent brings a preschooler to the emergency department for treatment of a dislocated shoulder, which allegedly happened when the child fell down the stairs. Which action should make the nurse suspect that the child was abused?

The child doesn't cry when the shoulder is examined.

A nurse is caring for a client recently diagnosed with acute pancreatitis. Which statement indicates that a short-term goal of nursing care has been met?

The client denies abdominal pain.

The home health nurse is completing the admission paperwork for a new client diagnosed with osteomyelitits who will be receiving home service intravenous therapy for the next month. The client is 32 years old and happily married. Which of the following findings will warrant further investigation? Select all that apply.

The client talks repeatedly about her death. • The client spends a great deal of time reflecting back on her teen years.

A client with a recent history of a stroke has been discharged from the rehabilitation facility with a walker. During the client's return visit to the physician's office, the nurse assesses his gait. Which finding indicates the need for further teaching about walker use?

The client's arms are fully extended when using the walker.

A nurse is caring for an 85-year-old client. What's the most important factor directly influencing this client's mental health?

The client's attitude toward life circumstances

The nurse is helping a client ambulate for the first time after 3 days of bed rest. Which observation will the nurse document that indicates the client tolerated the activity without distress?

The client's pulse and respiratory rates increased moderately during ambulation.

When interviewing the parents of an injured child, which of the following is an indicator that child abuse may be a problem?

The injury isn't consistent with the history or the child's age.

Which clinical characteristic affects client compliance?

The nurse-client relationship

An 86-year-old client is admitted to the hospital with an exacerbation of heart failure. He's confused and has inadvertently pulled out his I.V. catheters several times while attempting to get out of bed by himself. He was also found lying on the floor unharmed. When all other methods fail to keep the client in bed, the physician orders the use of physical restraints. Which nursing action reflects safe nursing care?

Tie the restraints to the bed frame using a quick-release knot.

A client who's taking aspirin for arthritis reports experiencing adverse effects. Which adverse effect indicates that a decrease in dose may be necessary?

Tinnitus

A client is prescribed transcutaneous electrical nerve stimulation (TENS) for pain relief. What is the rationale for using TENS?

To block painful stimuli traveling over small nerve fibers

A nurse is administering morphine, as prescribed, to a client before surgery. Why is this medication given preoperatively?

To facilitate anesthesia induction

The nurse is teaching a client how to rotate insulin injection sites. What is the purpose of rotating injection sites?

To prevent the formation of hard nodules

A nurse is caring for a child with hemophilia. Which information is appropriate to include when teaching home management to a child with hemophilia?

Toothbrushes should be held under warm water before use.

A client who has difficulty sleeping is asked to keep a sleep diary. Which information should the nurse instruct the client to keep in his diary?

Usual bedtime

A nurse immediately tells the truth about a medication error that she made. This nurse is following which ethical principle?

Veracity

A client with a history of heart failure is at risk for fluid volume excess. Which nursing intervention would ensure the most accurate monitoring of the client's fluid status?

Weighing the client at the same time each day

A nurse is preparing to begin one-person cardiopulmonary resuscitation (CPR). The nurse should first:

establish unresponsiveness.

The nurse has just removed an I.V. catheter from a client's arm because fluid has infiltrated the arm. The physician orders warm soaks for the area. Based on the principles of heat and cold application, the nurse would:

remove the warm compress after 20 minutes for at least 15 minutes.

A client scheduled for a colonoscopy has received nothing by mouth since midnight. The procedure is scheduled for 8 a.m. At 6:30 a.m. the nurse collects a fingerstick glucose sample that registers 40 mg/dl on the glucose monitor. The client is alert, has clear speech, and states, "I don't feel like my sugar is too low." Initially, the nurse should:

repeat the fingerstick glucose test.

The nursing instructor is lecturing on wounds and asked a nursing student which groups of clients are at increased risk for developing a wound infection. The instructor determines the student has a good understanding of clients at risk when the student appropriately identifies which group of clients? Select all that apply.

• "Clients who are undernourished." • "Clients who are diagnosed with diabetes mellitus and are non-compliant."

When the nurse enters a client's room, the client frowns and states, "I've had my light on for 20 minutes. It's about time you got here. I'm sick of this place and the staff." Which statement(s) by the nurse would be the most therapeutic? Select all that apply.

• "I understand that you must be frustrated. What can I do to help you?" • "You seem upset this morning." • "Your concerns are very important to me. Please tell me about them."

The LPN/LVN is assisting the RN to develop a plan of care for a client that will be having surgery. What statement(s) by the LPN/LVN demonstrates the importance of prevention of postoperative complications? Select all that apply.

• "You are less likely to get pneumonia if you cough and deep breathe following surgery." • "You can expect to control any pain with medications."

Two nurses are discussing which types of blood can be safely administered to a client with type AB negative blood. Which blood types can safely be administered to this client? Select all that apply.

• A negative • B negative

The nurse is teaching a client how to administer subcutaneous (subQ) insulin injections. Which appropriate sites would the nurse advise the client to use? Select all that apply.

• Abdomen • Anterior aspect of the thigh

An 80-year-old client comes to the clinic reporting shortness of breath. When listening to the client's lungs, the nurse hears crackles (intermittent, high- and low-pitched popping sounds in the lower bases of the lungs) during inspiration. In which conditions might the nurse auscultate crackles? Select all that apply.

• Acute respiratory distress syndrome • Pneumonia • Pulmonary edema

A client is ordered to receive a sodium phosphate enema for relief of constipation. Proper administration of the enema includes which steps? Select all that apply.

• Assisting the client into Sims' position. • Washing hands and putting on gloves. • Encouraging the client to retain the solution for 5 to 15 minutes.

While providing care to a married female client, the nurse notes multiple blue, purple, and yellow ecchymotic areas on her arms and trunk. When the nurse asks how she got these bruises, the client responds, "I tripped." What actions should the nurse take? Select all that apply.

• Document the client's statement and complete a body map indicating the size, color, shape, location, and type of injuries. • Assist the client in developing a safety plan for times of increased violence. • Provide the client with telephone numbers of local shelters and safe houses.

A client has a circular rash on her leg, accompanied by malaise, fever, headache, and joint aches. Laboratory studies and physical examination findings confirm that she has Lyme disease. Her physician prescribes doxycycline 100 mg by mouth twice per day. Which instruction should the nurse give the client about self-administration of doxycycline? Select all that apply.

• Drink a full glass of water with each dose. • If you are using oral contraceptives, use another form of birth control while taking this drug. • Take doxycycline 2 hours before or 3 hours after any vitamins or products that contain iron. • Avoid unnecessary or prolonged exposure to sunlight.

When receiving a client assignment on a telemetry unit, which assignment should the licensed practical nurse clarify as being out of the Practical Nursing (PN) scope of practice? Select all that apply.

• Initiating blood transfusion • Completing initial admission assessment

A client who is a resident in a long-term care facility was found on the floor by the nursing assistant. The nurse completes an incident report and documents the incident on the client's chart. Which of the following information should the nurse document on the client's chart? Select all that apply.

• Names of witnesses • Time health care provider was notified • Nursing interventions

A nurse is caring for a client who is disoriented to time, place, and person and is attempting to get out of bed and pull out an I.V. line that's supplying hydration and antibiotics. The client has a vest restraint and bilateral soft wrist restraints. Which of the following actions by the nurse would be appropriate? Select all that apply.

• Perform a face-to-face behavior evaluation every hour. • Tie the restraints in quick-release knots. • Document the client's condition. • Document alternative methods used before the restraints were applied. • Document the client's response to the intervention.

The nurse is preparing a discharge instruction sheet for a client on methimazole. What topics should the nurse include?

• Prevent pregnancy. • Take medication with food. • Watch for symptoms of jaundice.

A nurse is working with the family of a client who has Alzheimer's disease. The nurse notes that the client's spouse is too exhausted to continue providing care all alone. The adult children live too far away to provide relief on a weekly basis. Which nursing interventions would be most helpful? Select all that apply.

• Recommending community resources for adult day care and respite care • Encouraging the spouse to talk about the difficulties involved in caring for a loved one • Asking whether friends or church members can help with errands or provide short periods of relief

A client develops a temperature of 102° F (38.9° C). The nursing instructor concludes which actions by the student nurse requires further explanation and teaching? Select all that apply.

• The student covers the client with a heavy blanket. • The student helps the client select a low-calorie diet.

The Patient Self-Determination Act of 1990 requires all hospitals to inform clients of advance directives. What should the nurse tell the client about such advance directives as living wills and health care power of attorney? Select all that apply.

• They guide the client's treatment in certain health care situations. • The advance directive is only valid in the state where it was written and subject to that state's laws.

A female client taking antidepressant medication complains to the nurse that she has a decreased desire for sex, which is causing significant marital stress. Which response by the nurse would be the most appropriate?

"What are your thoughts on how you should handle this?"

A mother asks a nurse about measures for disciplining her toddler. Which recommendation by the nurse is best?

"When using a time-out, make sure your child knows the rules ahead of time."

A client is admitted to the hospital with an exacerbation of chronic systemic lupus erythematosus (SLE). The client gets angry when the call bell isn't immediately answered. What would be the most appropriate response for the nurse?

"You seem angry."

A client with renal cancer who has not yet been informed of his diagnosis asks the nurse what his test results showed. How should the nurse respond?

"You should probably talk to your physician."

A prenatal client says she can't believe she has such mixed feelings about being pregnant. She tried for 10 years to become pregnant and now feels guilty for her conflicting reactions. Which response is best?

"You're experiencing the normal ambivalence pregnant mothers feel."

An elderly client's husband tells the nurse he's concerned because his wife insists on talking about events that happened to her years ago. The nurse finds the client alert, oriented, and answering questions appropriately. Which statement made to the husband is correct?

"Your wife is reviewing her life."

5 Stages of Grief in order (DABDA)

1.Denial & isolation 2.Anger 3.Bargaining 4.Depression 5.Acceptance

A nurse is bed-bathing a client who has a decreased level of consciousness and a normal body temperature. What temperature should the water be?

110° to 115° F (43.3° to 46.1° C)

Which percentage of postpartum clients experiences "postpartum blues"?

20% to 25%

A nurse administered NPH insulin to a diabetic client at 7 a.m. At what time would the nurse expect the client to be most at risk for a hypoglycemic reaction?

4 p.m.

A nurse is performing a focused abdominal assessment. When can the nurse document that her client's bowel sounds are absent after listening for how long over each quadrant?

5 minutes

The nurse, in collaboration with the health care practitioner, is performing vision evaluation on four clients. When reviewing the data collection, which client's criteria would suggest to the nurse that a further visual evaluation is needed?

9-year-old with 20/20 vision in one eye and 20/40 vision in the other eye on 2 lines on the Snellen chart

The nurse just received shift report. Which client should the nurse see first?

A client on a morphine drip with a respiratory rate of 12 beats per minute

A child with iron-deficiency anemia is being treated with iron supplements. The child's mother brings the child to the clinic 3 months after the iron supplements were prescribed, and the child's hematocrit is about the same as it was 3 months ago. What information should the nurse first elicit from the mother?

A description of the child's stools

When reviewing an adult client's chart, which finding related to the bladder should the nurse identify as normal?

A nonpalpable bladder

The nurse at a substance abuse center is talking to a probation officer on the phone. The probation officer asks if a client is in treatment. The nurse responds, "No, the client you're looking for isn't here." Which statement best describes the nurse's response?

A violation of confidentiality because she informed the officer that the client wasn't there

For which rationale, when administering a Z-track injection, the nurse measures the correct medication dose and then draws a small amount of air into the syringe?

Adding air prevents the drug from flowing back into the needle track.

A client is confused and continuously attempts to get out of bed. The physician prescribes a vest restraint. When applying a vest restraint, what should the nurse keep in mind?

Allow room for the client to turn.

A nurse participating in planning care for a client who's in labor expects to monitor the client's blood pressure frequently. What is the significance of this nursing action?

Alterations in cardiovascular function affect the fetus.

The mother of a 3-year-old has been told that her child has a brain tumor. She initially begins to cry and accuses the physicians of lying. Which of the following stages is the mother most likely experiencing?

Anger

A client comes to the emergency department with the complaint of chest pain. After an electrocardiogram shows an irregular heart rate of 166 beats/minute, the client is admitted to the intensive care unit. Which nursing diagnosis is the priority?

Anxiety related to the fear death

A nurse needs assistance transferring an elderly, confused client to bed. The nurse leaves the client to find someone to assist her with the transfer. While the nurse is gone, the client falls and hurts himself. The nurse failed to do which of the following?

Arrange for continual care of the client.

A 6-year-old girl has been hospitalized with rheumatic fever for 4 weeks. Her symptoms have gradually subsided, and she's now ready for discharge. Which plan for her health care is most important for her future well-being?

Arrange for the administration of prophylactic antibiotics to prevent a recurrence of rheumatic fever.

Which intervention is best to help a 2-year-old child adapt to a hospitalization?

Ask one or both parents to stay with the child

The nurse is transporting a client with the diagnosis of tuberculosis to the radiology department for a chest X-ray. Which action taken by the nurse limits the spread of infection?

Ask the client to wear a surgical mask.

A nurse is assisting with the placement of a Levin nasogastric (NG) tube in a client with alcoholic cirrhosis. What's the best way to determine whether the NG tube is in the client's stomach?

Aspirate fluid from the tube and test its pH.

A nurse is gathering data on a client following an appendectomy. The blood pressure is 90/58 mmHg and the apical pulse is 108. What is the appropriate action by the nurse?

Assess the dressing for bleeding.

A client admitted to the mental health unit has exhibited physical behaviors that put him and others at risk. The nurse applies four-point restraints on the client without obtaining a physician's order or the client's consent. The nurse is at risk of being accused of which of the following?

Battery