240 part 2

The nurse auscultates the breath sounds of a toddler during an assessment and notes crackles over all lung fields. What would the nurse teach the parents about this finding?

"We need to validate the information obtained in this assessment."

A client who recently became quadriplegic as the result of a motor vehicle accident is experiencing multiple physical and emotional problems. To guide the care planning for this client, what type of nursing diagnosis would be most appropriate for the nurse to select?

A syndrome nursing diagnosis

The nurse and client have written the following outcome measure: "The client will eat at least 80% of each meal offered by 3/2." When should the nurse collect information to evaluate this outcome?

At the completion of each meal

Which intervention performed by the nurse is appropriate for assisting a client in meeting physiological needs based on Maslow's Hierarchy of Needs?

Cutting up food and opening drink containers for the client

A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain, which is interfering with the client's ability to ambulate. The nurse accurately documents which nursing diagnosis in the client's records?

Impaired Physical Mobility related to pain

A nursing instructor is teaching a student nurse about the layers of the skin. Which layer should the student nurse understand is a potential source of energy in an undernourished client?

Subcutaneous tissue

The nurse is caring for a 10-year-old client who is newly diagnosed with a seizure disorder. What variable would alter the nurse's plan for educating the client and parent?

The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years.

A client has been recently diagnosed with diabetes after receiving emergency treatment for a hyperglycemic episode. Which of the client's actions indicates that the client has achieved a cognitive outcome in the management of this new health problem?

The client is able to explain when and why the client needs to check the blood glucose level.

The nurse is assessing a client's surgical wound after abdominal surgery and sees viscera protruding through the abdominal wound opening. Which term best describes this complication?

evisceration

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

how often the client is bathing.

The purpose of obtaining a nursing history is to:

identify actual and potential health problems.

The nurse is providing care to a client with Lyme disease. The nurse identifies the vector of this infection as:

parasite

The nurse is recovering from a mild upper respiratory infection with no fever. The nurse is assigned to care for four clients. What is the appropriate nursing action to prevent clients from getting the infection?

perform meticulous hand hygiene and don a new mask with each client encounter

A nurse makes a nursing diagnosis of Constipation after a client reports not defecating on the last trip to the bathroom. The nurse has no other information on the client's defecation history. This is an example of:

premature closure.

A client is experiencing generalized weakness and body aches. In the progress of infection, the client is in the:

prodromal period

A group of students is reviewing information about cellular and humoral immunity. The group demonstrates understanding of these concepts when they identify what as a function of cellular immunity?

reactivate if the same antigen reappears

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a pale pink drainage on the dressing. Which drainage type should the nurse document?

serosanguineous

A nurse manager is conducting peer reviews of the staff on the critical care unit. Which person would the nurse manager select to evaluate a registered nurse who is certified in critical care?

Another registered nurse with critical care certification

Which is not considered a skin appendage?

Connective tissue

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.

Which guideline should the nurse follow when including interventions in a plan of care?

Date the nursing interventions when written and when the plan of care is reviewed.

The client, who is 8 weeks pregnant as the result of a rape, tells the nurse, "I do not want to have this baby, but I have always believed that abortion is a sin. I don't know what to do." What nursing diagnosis would be most appropriate for the nurse to formulate?

Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement

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

A client is brought to the emergency department. The client is unkempt, reports being too busy to eat, and paces in the examination room stating there is no time to sit for treatment. Which nursing diagnosis will the nurse rank as the highest priority for this client?

Ineffective Impulse Control

For a hospital to meet criteria regarding nursing care established by The Joint Commission, the nurse must conduct which type of assessment?

Initial

Which statement on a plan of care should a nurse identify as a nursing intervention?

Perform range-of-motion exercises to all of the client's joints each morning.

A nurse is caring for a client who has an avulsion of her left thumb. Which description should the nurse understand as being the definition of avulsion?

Tearing of a structure from its normal position

The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the education plan? Select all that apply.

The client is blind. The client denies the need for education

One of the primary factors that the nurse considers when setting priorities for the client in the acute care setting after cardiac surgery is the client's:

condition

A client comes into the clinic for a routine postoperative visit. While the nurse is assessing the level of pain, the client states that there is occasional discomfort but that pain levels have improved daily since returning home from the hospital. What should the nurse's response be regarding the client's plan of care?

Continue the plan of care.

A client with multiple leg fractures following a motor vehicle accident tells the nurse, "I am going crazy here. I have to wait 2 months before I can practice walking." What is the priority nursing diagnosis?

Deficient Diversional Activity

A client comes to the emergency department with a productive cough and an elevated temperature. Which type of assessment would the nurse most likely perform on this client?

Focused

A client with diabetes mellitus has been admitted to the hospital in diabetic ketoacidosis. During the admission assessment of the client, the nurse learns that the client is not following the prescribed therapeutic regimen. The client states, "I don't really have diabetes. My doctor overreacts." What is the most appropriate diagnosis for this client's health problem?

Ineffective Health Maintenance related to client's denial of illness

A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on the client's activities of daily living (ADLs) during the period of recovery. When should the nurse begin discharge planning to address this client's ADLs?

On the client's admission to the hospital

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?

Perform vital signs and blood glucose level.

A client who was admitted to the acute care unit with angina pectoris is no longer having chest pain. Based on this assessment, what does the nurse decide to do with the plan of care for chest pain?

Terminate the plan of care related to the nursing diagnosis of chest pain.

The nurse is developing goals for a client who has been admitted for an acute myocardial infarction. What goal written by the nurse requires revision?

The client will understand the effects of smoking related to heart disease.

A client undergoing chemotherapy who has had a stroke will need a hospital bed at home. Which essential information does the nurse teach the family to maintain a safe client care environment? Select all that apply.

Check that the bed wheels are locked. Keep bed side rails up when your family member is in the bed

A client with end-stage chronic obstructive pulmonary disease (COPD) has the nursing diagnosis "Activity Intolerance." Which expected client outcome most directly demonstrates resolution of the problem?

Client will alternate rest periods with exercise throughout the day.

After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action?

Communicate with the physician for additional orders.

The nurse records the name, age, and genetic background of the client. The data are components of which tool?

Health history

A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care?

Nurse case manager

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?

Nurses do carry out interventions in response to a physician's order.

The formulation of nursing diagnoses is unique to the nursing profession. Which statement accurately represents a characteristic of diagnosing?

Nurses write nursing diagnoses to describe client problems that nurses can treat.

The nurse admitting a client with a new diagnosis of diverticulitis plans to teach the client about managing the disorder after discharge. What nursing intervention most completely meets the client's needs?

Start from client's knowledge, teach about diet modifications, and check for learning.

Which nursing action reflects evaluation?

The nurse assesses the client's response to pain medication.

A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn?

Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown

What would be a nursing priority when assessing a client who weighs 250 lb (112.50 kg) and stands 5 ft, 3 in (1.58 m) tall?

Assess blood pressure with a large cuff.

Which is a psychomotor client goal?

By 18AUG2015, the client will demonstrate improved motion in the left arm.

A nurse is preparing to help a client with a skin infection have a tub bath. In which way can the nurse ensure the client's safety?

Check that the bathroom has a nonskid floor.

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound

Desiccation

A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client?

Fungi

Which piece of personal protective equipment (PPE) should be removed first?

Gloves

Which are psychomotor outcomes? Select all that apply.

The client accurately draws up insulin. The client safely ambulates using a walker.

A nurse is providing care to a client who has Salmonella food poisoning. The nurse understands that this pathogen was transmitted by which mechanism?

Vehicle

During the initial assessment of a newly admitted client, the nurse has clustered data as follows: range of motion with gait, bowel sounds with usual elimination pattern, and chest sounds with respiratory rate. The nurse is most likely organizing assessment data according to:

body systems.

Which client would the nurse consider the most infectious?

A client who is in the prodromal stage

Which client situation most likely warrants a time-lapse nursing assessment?

An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit.

The nurse is preparing to evaluate the goals set for a newborn and mother. What physiologic goals will the nurse evaluate for effectiveness? Select all that apply.

By 4/6/20, the newborn will demonstrate 2 hours of sleep prior to breastfeeding at night. By 4/6/20, the mother will demonstrate a pain rating of 0 on a 0 to 10 scale. Before discharge, the baby with a birth weight of 7 lb, 6 oz (3.3 kg) will have reached a target weight of 8 lb (3.6 kg).

Which is the best source of information for the nurse when collecting data for an assessment?

Client

The nurse is inserting a foley catheter for a client. Which nursing action is appropriate if the sterile field is broken during this procedure?

Don another pair of sterile gloves.

The nurse is preparing to conduct an assessment on a new client of Chinese descent who is being admitted for abdominal surgery. Which step should the nurse prioritize during the assessment with this client?

Explain the nurse will need to touch the client during the assessment

A facility has participated in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey and received the results. A nurse is part of the team reviewing the information. For which areas should the nurse expect the survey to provide information? Select all that apply.

Facility cleanliness Courteous treatment Pain control

The nurse is caring for a client with diabetes who has thick toenails. What is the appropriate nursing intervention?

File, rather than cut the nails.

Which best describes the purpose of nursing diagnoses?

Identification of client problems that nurses can treat independently

The nurse is caring for a client for the third day in a row on the hospital unit. At the client's evening vital sign assessment, the nurse notices that the radial pulse is much slower than the apical pulse. This finding is new. What should the nurse do next?

Notify the physician of the change and document the finding.

What are specific measurable and realistic statements of goal attainment?

Outcomes

The nurse developed a plan for a client and has been working with the client for several months. The client reports feeling better due to an ability now to participate actively in water aerobics. What type of outcome is this?

Psychomotor

The nurse is caring for a woman who informs the nurse that she needs assistance to remove and clean her glass eye. What actions by the nurse are most appropriate to accomplish the task?

Pull down on the lower lid and exert slight pressure below the lid.

Before implementing any planned intervention, which action should the nurse take first?

Reassess the client to determine whether the action is needed.

Which nursing action is appropriate when providing foot care for a client?

Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms.

The nurse is preparing a sterile field for a dressing change. How would the nurse add paper-wrapped sterile items to the sterile field?

Separate the sealed flaps and drop contents onto field.

Which documentation note regarding an assessment of eroding tooth enamel is most appropriate?

The client is at risk for caries due to eroding tooth enamel.

The nurse is caring for a client who has a pressure injury on the back. What nursing intervention would the nurse perform?

The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair.

What is the purpose of establishing a nursing diagnosis?

To describe a functional health problem

A client is required to have nothing by mouth (NPO) for 8 hours prior to a test scheduled for tomorrow. What action by the nurse best communicates this change in basic care needs for the client?

Updating the diet orders in the client's plan of care

In which situation would it be appropriate to shave the beard of an unconscious client without his permission?

When inserting an endotracheal tube

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention?

applying sterile dressings with normal saline over the protruding organs and tissue

A new mother is having difficulty breastfeeding a newborn infant. A goal was established stating that the baby would be nursing every 2 to 3 hours by age 1 week. The mother presents to the follow-up center at 1 week and reports having discontinued breastfeeding. The nurse evaluates the original goal as:

completely unmet.

The charge nurse is working on client assignments for the incoming shift. A client with methicillin-resistant Staphylococcus aureus (MRSA) is assigned to a nurse. Which type of client should the charge nurse avoid assigning to the incoming nurse?

the client with cancer and with neutropenic precaution

A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury?

use pillows to maintain a side-lying position as needed