3015: Exam #2

The home health nurse is visiting a new client who has recently started using an oxygen concentrator. After assessing the home environment, which comment should the nurse PRIORITIZE?

"Have you discussed a back-up system with you health care provider in case your electric goes out?"

The expected outcome for a client with a new diagnosis of osteoporosis is "Client will implement actions to promote safety and bone strength." Which statement by the client is the BEST indicator that the outcome exceptions have been met?

"I walk daily wearing low-heeled shoes"

The nurse provides care for a client with chronic bronchitis and a decreasing oxygen saturation. Which factor(s), if assessed, indicate a deteriorating condition? Select all that apply.

- Tachypnea - Tachycardia - Shortness of breath - Wheezing and crackle in lungs

A nurse is measuring the intake and output of a client who is dehydrated. What is the average adult daily fluid intake in milliliters that the nurse would use as a comparison?

2,600 mL

A nurse monitoring the intake and output of fluids for a client with severe diarrhea knowns that normally how much body fluid is lost via the gastrointestinal tract?

300 mL

A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The client's SaO2 is 90% on pulse oximetry. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:

6 L/minute

The nurse is conducting a nursing history of a client with a respiratory rate of 30 breath per minute, audible wheezing, and nasal flaring. During the interview, the client denies problems with breathing. What action should the nurse take next in regard to the discrepancy?

Clarify discrepancies of assessment data with the client

The nurse is admitting a new client who has had a chest tube on the right side. Which action should the nurse prioritize for this client?

Coughing and deep breathing at least q2h while awake

An older adult client visits a health care facility for a scheduled physical assessment. During the assessment, the client reports difficulty breathing. Which suggestion could the nurse make to improve the client's respiratory function?

Drink liberal amounts of fluids

Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat?

Eat smaller meals that are high in protein

When developing a nursing diagnosis for a client, which should the nurse do first?

Identifying the significant data

The nurse has identified a collaborative problem of Risk for Complication of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's MOST appropriate action?

Notify the physician for additional orders

An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations?

Offer small amounts of preferred beverage frequently

The nurse is assessing the client's behavioral response to a nursing intervention. This type of evaluation is known as:

Outcome evaluation

A nurse in a community health center has been having regular meetings with a client who wants to stop smoking. Which outcome decision option should the nurse document if the client has not smoked fore 7 months?

Outcome met

Which is the BEST example of person-centered care provided by a registered nurse?

Reassuring a client who is anxious about a procedure

Which is an accurately phrased risk nursing diagnosis?

Risk for Falls related mobility

Which nursing diagnosis has the PRIORITY when caring for an older adult client with Alzheimer disease?

Risk for injury

A specially trained nurse has inserted a PICC line. What would be done NEXT?

Send the client to the radiology department

A nurse is educating a preoperative client on how to effectively deep breath. Which instruction would be included?

"Make each breath deep enough to move the bottom ribs"

Which question would MOST helpful to the nurse in facilitating critical thinking during outcome identification and planning?

"What problems require my immediate attention or that of the team?"

Which behaviors are characteristic of a nurse who is a critical thinker? Select all that apply.

- Alert to context so that the need for modification can be identified and changes to the plan of care can be made - Responsible and accountable for own actions

A nurse is developing the postoperative plan of care for a client admitted with a fractured hip who has undergone surgery to repair it. Which intervention would the nurse identify as a nurse-initiated intervention? Select all that apply.

- Assess the client's pain level every 2 hours - Turn the client every 2 hours per turning schedule - Teach the client how to perform relaxation as a pain relief strategy

The nurse is creating a concept map to plan for the care of a client. Place in order the steps the nurse will perform to create the concept map.

- Collect client problems and concerns on a list - Connect and analyze the relationships - Create a diagram - Keep in mind key concepts - Apply the concept map to client care

A client is to receive a blood transfusion. Immediately after initiating the transfusion, the nurse suspects that the client is experiencing a hemolytic reaction based on which finding? Select all that apply.

- Fever - Facial flushing - Lower back pain - Hematuria

at 0730, the nurse notes that the client states that pain is a 7 on a scale of 0 to 10. Based on this assessment, the nurse administers pain medication to the client. At 0800, the nurse evaluates the client and finds that pain is a 4 on a scale of 0 to 10. Which example of documentation MOST clearly communicates the initial morning assessment?

0730: Client reports pain is a 7 on a scare of 0-10. Morphine sulfate 2 mg IV administered

A client is unconscious and unable to provide input into outcome identification. Which plan of care will the nurse initiate and share with the family?

A plan designed to support the client physically

After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type?

Actual

A client reports to the nurse quitting smoking 6 months ago after being diagnosed with lung cancer. The nurse recognizes this change in behavior is which type of outcome?

Affective

A nurse is interviewing an asthmatic client who has a high respiratory rate and at times has difficulty breathing. The client is restless and at current can only speak a few words before pausing to catch a breath. What appropriate nursing diagnosis should the nurse document?

Altered verbal communication related to the breathing problem

The nurse is working with a client who is having a difficult time accepting a new diagnosis of type 2 diabetes. The nurse pulls up a chair and hold the client's hand while listening to the client's concerns. What additional type of nursing supportive intervention type could the nurse provide?

Arranging for clergy visit with the client

When planning initial care for a 16-year-old and the client's newborn, the nurse formulates a nursing diagnosis of "Risk for Impaired Attachment." What would be the nurse's MOST appropriate action to take next?

Assess the client's interaction with the newborn

A client is scheduled for insertion of a peripherally inserted central catheter. When assisting with the procedure, the nurse would except that which site would most likely be used?

Basilic vein

The nurse is caring for several clients. Which intervention can the nurse direct the unlicensed assistive personnel (UAP) to perform?

Bathe a client with stable angina who has a continuous IV infusing

A client with congestive heart failure has dyspnea while ambulating to the bathroom. The nurse selects the nursing diagnosis of "Activity Intolerance" to address this health problem. Which etiology would be appropriate to select for this nursing diagnosis?

Compromised oxygen transport

A nurse is evaluating a client to determine outcome achievement. The nurse determines that the client's outcome was partially met. When documenting the evaluative statement, the nurse records which other information?

Data the support the decision of the outcome being partially met

A client with advance Alzheimer's disease has a nursing diagnosis of "Risk for Aspiration." What would the nurse select as an appropriate etiology for this diagnosis?

Decreased level of consciousness

A nurse has developed a plan of care for a client whose spouse recently died. The nurse assigned the client a nursing diagnosis of: Risk for Loneliness. When the nurse is evaluating the plan, the client tells the nurse new information about having an active social life and being satisfied with social activities. What should the nurse do next?

Delete the nursing diagnosis

The nurse observes a client practice pursed-lip breathing in preparation for discharge. Which action should the nurse point out needs correcting?

Exhales to a count of 4

A nurse is caring for a client who has pneumonia. What is an appropriate nursing diagnosis?

Ineffective Airway Clearance

A nursing instructor is teaching a class on the mechanics of respiration and the process of ventilation. The instructor determine that the education was successful when the students identify which activity as occurring during inspiration?

Intercostal muscles contract

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 nurse is examine alternatives and judging the worth of evidence as part of preparing the plan of care for a client. The nurse would most likely be involved in which phase of the nursing process?

Planning

What is the PRIORITY goal for the activity in which the nurse is engaging, related to the administration of a prescribe IV solution?

To assure the IV solution is appropriate for this administration

Which purpose of the evaluation phase of the nursing process is a PRIORITY during client care?

To examine the client's behavioral response to the care received

The nurse is performing a physical assessment on a newly admitted client. During the assessment the nurse notices the client grimacing and holding the abdomen. When the nurse asks the client whether the client is in pain, the clients answers, "No." What is the BEST thing for the nurse to do next?

Validate the data

Identifying the kind and amount of nursing services required is a possible solution for:

inadequate staffing

The nurse is providing discharge teaching to a client going home with oxygen therapy. Which statements made by the client would indicate to the nurse that the teaching was effective? Select all that apply.

- "I will not allow smoking within 10 feet of my oxygen" - "I will keep the oxygen tank away from direct sunlight or heat"

The nurse is responsible for recognizing significant data when developing nursing diagnoses. Which significant data would indicate a health problem may exist? Select all that apply.

- The client has a blood pressure reading of 150/90 mm Hg - During the assessment, the client is sweating and short of breath - The client only answers yes or no questions

Which are cognitive client outcomes? Select all that apply.

- The client list the side effects of digoxin - The client describes how to perform progressive muscle relaxation - The client identifies signs and symptoms of hypoglycemia

A client is receiving a transfusion of packed red blood cells, and the nurse has obtained the first set of vital signs after initiating the transfusion. These closely match the pretransfusion vital signs with the exception of a 1 degree F (0.5 degree C) increase in the oral temperature. The client denies other symptoms and is not in distress. What is the nurse's MOST appropriate action?

Administer acetaminophen as prescribed

A nurse is caring for a client who breaths very shallowly and has been reporting sever back pain. What suggestion could the nurse make to help the client breather efficiently?

Encourage the client to take deep breaths

The client is experiencing respiratory distress and the nurse places the client in a high Fowler position. With action does the nurse take NEXT?

Ensure airway patency

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

A 16-year-old was admitted to the medical unit one hour ago for sickle cell crisis. Vital signs are as follows: temperature, 98.24 F (36.8 C) sublingual; hear rate, 95 beats/min; respiratory rate 20 breaths/min; blood pressure, 130/65 mm Hg. The client rates pain as a 9/10. The nurse is talking with the medical resident on service to discuss client orders. Which order is the nurse likely to request first for the client?

Opioid analgesic to treat pain

A nurse is caring for an older adult client in a long-term care facility and notices that the bed linens are damp when the client gets up in the morning. The nurse suspects that the client has been incontinent of urine and collects more data to form a conclusion. What type of problem has the nurse determine this is?

Possible problem

A nurse has developed a plan of care for an adult client. What nursing function is important when using nursing diagnoses to guide the care of this client?

Prioritize the nursing diagnoses

A nurse demonstrates critical thinking when applying the nursing process to client care. Which behavioral components would the nurse likely use during the assessment phase? Select all that apply.

- Asking relevant questions - Exploring ideas - Recognizing issues

Which nursing diagnoses are stated correctly? Select all that apply

- Deficient Fluid Volume related to abnormal fluid loss - Nutrition Deficit related to inability to eat a balanced diet

Which nursing diagnosis(es) is correctly written with its three parts? Select all that apply

- Ineffective Health Maintenance related to lack of motivation as evidenced by client's statement of lack of interest in improving health - Constipation related to side effects of antidepressants as evidenced by passage of hard, dry stool

Which actions should a nurse perform when inserting an oropharyngeal airway? Select all that apply.

- Wash hands and put on PPE, as indicated - Rotate the airway 180 degrees as it passes the uvula - Remove airway for a brief period every four hours or according to facility policy

A client is being admitted from the emergency room reporting shortness of breath, wheezing, and coughing. What would the nurse formulate as an appropriate nursing diagnosis?

Ineffective Airway Clearance

A client using home oxygen asks the nurse about changing to an oxygen concentrator. What is the appropriate nurse response select all that apply.

- "It collects and concentrates oxygen from room air" - "It eliminates the need for a central reservoir of piped oxygen" - "You may notice an increase in your electric bill" - "It costs less than oxygen supplied in portable tanks"

Which actions would a nurse perform after selecting a site and palpating accessible veins in order to start an IV infusion? Select all that apply.

- Advance the needle or catheter into the vein. A sensation of "give" can be felt when the needle enters the vein - When blood returns through the lumen of the needle or the flashback chamber of the catheter, advance device into vein until the hub is at the venipuncture site - Release the tourniquet, quickly remove the protective cap from the IV tubing, and attach the tubing to the catheter or needle.

The nurse is providing care for a client who experienced an ischemic stroke 5 days ago. The client now has difficulty swallowing liquids and solids, has weakness on the right side of the body, and is incontinent of bowel and bladder. Which priority nursing diagnoses should the nurse identifying and document in the care of this client? Select all that apply.

- Bowel incontinence - Impaired swallowing - Impaired physical mobility

A nurse is developing a plan of care for a client and determine appropriate outcomes and interventions for this client. Which variable would be MOST appropriate for the nurse to address to ensure that the care plan meets the client's needs? Select all that apply.

- Client's ability to participate - Client's developmental stage - Client's cultural background - Client's socioeconomic status

The nurse is preparing to interview several clients during clinic hours. What language difficulty might a nurse encounter while performing various interviews in a diverse population of clients?

- Clients not being fluent in the same language as the nurse - Clients having a limited education - Clients fearing saying the wrong thing

The nurse is monitoring a client with continuous pulse oximetry. What action(s) by the nurse are important to obtain accurate results? Select all that apply

- Correlate the pulse oximetry reading with the client's heart rate. - Use the forehead sensor if cardiac output is low. - Determine if the client has a pre-existing condition affecting the oxygen saturation

Using the nursing process, place in order the steps in concept map care planning:

- Develop a graph that has boxes for key problems and nursing diagnoses - Analyze and categorize the client data, including prioritizing nursing diagnoses - Analyze relationships among the nursing diagnoses and draw lines among the boxes - Identify goals/ outcomes and interventions for each nursing diagnosis - Evaluate the client's response

The nurse performed a physical lung assessment on a client who reports shortness of breath. The nurse collected the following data. What is the proper sequence of data collection?

- Exhalation is prolonged. Respirations are 24 breaths/minute. Chest is barrel shaped. - Skin on chest is warm and dry. Decreased tactile fremitus is present. - Percussion reveals hyperresonant sounds. Chest excursion is less than normal. - Breath sounds are adventitious in lower lobes.

The nurse is caring for a client who has just had a lower leg amputation following a motor vehicle accident. During the planning phase of the nursing process, The nurse will prioritize which problem(s) on the first postoperative day? Select all that apply.

- Infection risk - Impaired coagulation potential

The nurse is caring for a client with emphysema. When teaching the client pursed-lip breathing, the nurse will include which instruction(s)? Select all that apply.

- Inhale slowly through the nose for a count of three. - Shape the lips as if you were about to blow a whistle. - Over time, begin to increase the length of the exhale. - Exhale slowly through pursed lips. - Ensure that the exhale lasts twice as long as the inhale.

Which nursing actions would be performed when preparing an IV solution and tubing to initiate intravenous therapy? Select all that apply.

- Maintain aseptic technique when opening sterile packages and IV solution - Clamp tubing, uncap spike, and insert into entry site on bag as manufacturer directs - Remove cap at end of tubing, release clamp, and allow fluid to move through tubing - Apply label to tubing reflecting the day/ date for next set change, per facility guidelines

The nurse is teaching a client and caregiver how to properly use an incentive spirometer. Place the following steps in correct order:

- Note the goal of inhalation - Exhale normally - Seal the lips around the mouthpiece - Inhale slowly until reach desire volume - Hold breath for four seconds - Remove mouthpiece and breath normally

A nurse is using the nursing process to provide care to a client admitted to the facility. During the assessment phase, which activities would the nursing likely perform? Select all that apply.

- Obtain a baseline oxygen saturation level - Check the results of the client's blood work - Obtain a weight

A nurse identifies an area where client care has been compromised. What steps should the nurse take to improve performance? Select all that apply.

- Plan a strategy using indicators - Assess the change - Discover a problem - implement a change

A nurse selects the basilica vein as the intended site for the insertion of an IV catheter. The nurse understands that which bone would act as natural splints to allow the client greater freedom of movement? Select all that apply.

- Radius - Ulna

Which normal conditions would a nurse expect to find when performing a physical assessment of a client's respiratory system? Select all that apply.

- Slightly contoured chest with no sternal depression - Anteroposterior diameter of the chest less than the transverse diameter - Bronchial, vesicular, and bronchovesicular breath sounds

Which examples are essential components for delegating nursing care to an unlicensed assistive personnel (UAP)? Select all that apply.

- The UAP has sufficient knowledge and skill for completing the task - The nurse has clearly communicated instructions to the UAP - The UAP can verbalize what information to report to the nurse

The nurse is assessing an adult client who has presented to the emergency department with general weakness. The nurse reviews the client's health record to find there is no history of underlying health conditions. The nurse will begin preparing for the insertion of a peripheral intravenous line if which assessment finding(s) are present? Select all that apply

- The client reports using laxative substances daily. - The client has been vomiting for several days. - The client has a serum potassium level of 2.0 mEq/l (2.0 mmol/l). - The client has severe iron-deficiency anemia

A health care provider has prescribed oxygen to be delivered at 8 L/minute for a client who does not have a tracheostomy. Which oxygen delivery device(s) will the nurse consider using? Select all that apply.

- simple mask - partial rebreather mask

The nurse is preparing to flush a client's peripheral venous access device. Which observable intervention BEST assures continued effective venous access at this location?

Anchoring extension tubing near entry site with tape

A 19-year-old college basketball player is being evaluated for injuries after a skiing accident. The nurse determines that the client has a pulse of 52 beats/min. What would be the MOST appropriate way for the nurse to determine the significance of the client's hear rate?

Ask the client whether the heart rate is normal for the client

A nurse is preparing to insert a intravenous line and begin administering intravenous fluids. The client has a visitors in the room. What should the nurse do?

Ask the client whether visitors should remain in the room

Which action would the nurse perform in the assessment phase of the nursing process?

Asking the client whether the client has cultural preferences

The nurse is planning care for a client who is prescribed a simple mask for oxygen delivery. What intervention will the nurse include in the plan of care?

Assess the client for anxiety due to claustrophobia

A nurse is formulating a nursing diagnosis for a client with a respiratory disease. Which nursing diagnosis would be correct?

Ineffective Airway Clearance related to thick mucus

A nurse caring for a client with a respiratory condition notices the client's breathing pattern is getting more irregular and the rate has greatly increased from 18 to 32 breaths per minute. The nurse notes that this client's vital signs are assessed once every shift, but believes the assessment should be done more frequently. Who is responsible for increasing the frequency of this client's assessments?

The nurse