409 RQ 1

The nurse receives a telephone call from the postanesthesia care unit, stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client?

assess the patency of the airway

A client is recovering from abdominal surgery and has a large abdominal wound. The nurse would encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing?

oranges

The nurse is providing medication instructions to an older client with chronic heart failure who is taking digoxin daily. The nurse explains to the client that decreased lean body mass and decreased glomerular filtration rate, which are age-related body changes, could place the client at risk for which complication with medication therapy?

increased risk for digoxin toxicity. at risk because of decreased lean body mass and age associated decreased GFR.

The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse needs to call the surgeon to clarify that which medication would be given to the client and not withheld?

prednisone steroid prolonged use causes adrenal atrophy reducing the body's ability of withstanding stress

8. A parent calls a neighbor who is a nurse and tells the nurse that their 3-year-old child has just ingested liquid furniture polish. The nurse would direct the parent to take which immediate action?

call the poison control center

A postoperative client has been placed on a clear liquid diet. The nurse would provide the client with which items that are allowed to be consumed on this diet? Select all that apply.

broth, coffee, gelatin. clear liquid diet includes transparent liquids and are liquid at room temperature.

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse?

can you share with me what you've been told about your surgery

The nurse instructs a client with chronic kidney disease who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu?

cream of wheat, blueberries, coffee. controlled amounts of sodium, phosphorus, Ca, K and fluids are needed for a CKD pt.

The nurse is giving report to an assistive personnel (AP) who will be caring for a client who has hand restraints (safety devices) applied. How frequently would the nurse instruct the AP to remove the restraints to allow for muscle activity?

every 2 hours permits muscle exercise and promotes circulation

Contact precautions are initiated for a client with a health care-associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The nurse prepares to provide colostomy care and would obtain which protective items to perform this procedure?

gloves, gown, goggles, and a mask or face shield.

A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result would be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed?

hemoglobin, 8.0g/dL

The nurse has given the client instructions about crutch safety. Which statements indicate that the client understands the instructions? Select all that apply.

i should not use someone elses crutches. i need to remove any scatter rugs at home. i need to have spare crutches and tips available.

The nurse is reviewing dental care with a client who is edentulous and wears dentures. Which client statement indicates an understanding of proper dental care?

i will remove my dentures before bed and keep them in my labeled denture cup covered with water. if they are not covered with water they can warp and dry out.

The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication?

increasing restlessness could indicate potential complication such as hemorrhage, shock, or pulmonary embolism.

The community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching was effective? Select all that apply

inhalation of bacterial spores, through a cut or abrasion in the skin, ingestion of contaminated undercooked meat.

A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse responds, knowing that which would most likely result from this improper crutch measurement?

injury to the brachial plexus nerves bearing weight on the crutch can cause injury.

The nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of which food?

legumes.

The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and would include which food items on the list? Select all that apply.

margarine, cream cheese, luncheon meats.

The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats per minute. On the basis of this finding, what is the priority nursing action?

notify the obstetrician at 38 weeks gestation the normal FHR range is from 110-160BPM. a lower or higher FHR may mean the fetus is in distress.

A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse would take which most appropriate action in the care of this client?

obtain a telephone consent from a family member, following agency policy.

The nurse is teaching a client who has iron-deficiency anemia about foods the client needs to include in the diet. The nurse determines that the client understands the dietary modifications if which items are selected from the menu?

oranges and dark green leafy vegetables. good source of iron and vitamin c which increases iron absorption.

11. The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the primary health care provider (PHCP), and the PHCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? Select all that apply.

peas, nuts, cauliflower. normal Na= 135-145. these options are low in sodium and a good source of phosphorus.

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action

activate the fire alarm

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?

urinary output of 20ml/hr urine output should be maintained at a minimum of 30ml/hr

Which purposes of placental functioning would the nurse plan to include in a prenatal class? Select all that apply.

it is the way the baby gets food and oxygen. it provides an exchange of nutrients and waste products between the birthing parent and developing fetus.

A nursing student is preparing to present a clinical conference to peers regarding Freud's psychosexual stages of development, specifically the anal stage. The student would plan to explain to the group that which characteristic relates to the anal stage?

this stage is associated with toilet training. child gains pleasure from the elimination of feces from their retention.

The nurse is preparing to provide wound care to a client with a stage 1 pressure injury. Which dressing would the nurse expect to be prescribed in the treatment of this wound?

transparent dressing

The nurse is preparing to irrigate a client's sigmoid colostomy. The nurse would plan for which intervention to perform this procedure?

instilling 500-1000ml of lukewarm tap water through the stoma. promotes regular colon emptying.

The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques

use of an incentive spirometer will help prevent pneumonia

The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse plans to provide dietary teaching and would focus on foods high in which vitamin that may be lacking in a vegan diet?

vitamin b12 vitamin b12 comes from animal sources.

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds would the nurse expect to hear when performing a respiratory assessment on this client?

wheezes.

11. The nurse working in the emergency department (ED) is assessing a client who recently returned from Nigeria and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action would the nurse take next?

isolate the client in a private room suspect potential for ebola virus

Which statement by the student indicates an understanding of the ductus venosus?

it connects the umbilical vein to the inferior vena cava.

When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response?

it promotes the fertilized ovums normal implantation in the top portion of the uterus.

A primary health care provider has ordered digital removal of stool for a constipated client. How would the nurse position the client for this procedure?

left lateral side-lying position follows the anatomical curvature of the colon.

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which would the nurse include for this type of assessment? Select all that apply.

auscultating lung sounds, obtaining the clients temperature, obtaining information about the clients respirations.

A client with Crohn's disease has just had surgery to create an ileostomy. The nurse assesses the client in the postoperative period for which most frequent complication of this type of surgery?

fluid and electrolyte imbalance.

A client who does not speak English arrives at the triage desk in the emergency department and states to the nurse that an interpreter is needed. Which is the best action for the nurse to take?

page an interpreter from the hospitals interpreter services.

The staff nurse reviews the nursing documentation in a client's chart and notes that the wound care nurse has documented that the client has a stage 2 pressure injury in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area?

partial thickness skin loss with exposed dermis.

The nurse is preparing to instruct a client with hypertension on the importance of choosing foods low in sodium. The nurse would plan to teach the client to limit intake of which food?

smoked salami.

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which?

a blowing or swooshing noise.

The nurse is preparing to describe Piaget's cognitive developmental theory to pediatric nursing staff. The nurse would plan to tell the staff that which child behavior is characteristic of the formal operations stage?

childs basic abilities to think abstractly and problem solve are similar to an adults.

The nurse is preparing to initiate an intravenous (IV) line containing potassium chloride using an IV infusion pump. While preparing to plug the pump cord into the wall, the nurse finds that no outlet is available in the wall socket. The nurse would take which action?

contact the electrical maintence department for assistance. potassium chloride needs to be administered by IV infusion pump.

A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because they have been "bored" with the clear liquid diet. The nurse would prepare to offer which full liquid item to the client?

custard.

The nurse is preparing to give a full bed bath to a client. Which question is most important for the nurse to ask the client before beginning the bed bath?

do you have any allergies

The nurse prepares to provide instructions to a client with a low potassium level about the foods that are high in potassium and plans to tell the client to consume which foods? Select all that apply.

raisins, potatoes, cantaloupe, strawberries. normal K level = 3.5-5.

The nurse is providing instructions to the assistive personnel (AP) regarding care of an older client with hearing loss. What would the nurse tell the AP about older clients with hearing loss?

they respond to low-pitched tones. degenerative changes in the inner ear lead to decreaesed hearing ability where they respond less to high frequency sounds.

The nurse would plan to make which statement to a pregnant client found to have a gynecoid pelvis?

your type of pelvis is the most favorable for labor and birth. gynecoid pelvis is a normal pelvis and is the most favorable for successful labor and birth.

The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement?

i need to continue to take the aspirin until the day of surgery

3. The nurse is creating a plan of care for a client scheduled for surgery. The nurse would include which activity in the nursing care plan for the client on the day of surgery?

have the client void immediately before going into surgery

The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees identify which client as most typically a victim of abuse?

a person who has advanced parkinsons disease one physical or mental impairment limits their ability to perform ADLSs puts more at risk of abuse.

A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem?

a physical obstruction to the transmission of sound waves.

The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep?

i drink hot chocolate before bedtime. caffenated beverage

The student responds correctly by explaining which as characteristics of amniotic fluid? Select all that apply.

1.Allows for fetal movement. 2.Surrounds, cushions, and protects the fetus. 3.Maintains the body temperature of the fetus. 4.Can be used to measure fetal kidney function.

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions would the nurse take? Select all that apply.

1.Contact the surgeon. 2.Instruct the client to remain quiet. 3.Prepare the client for wound closure. 4.Document the findings and actions taken

The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicate effective coping? Select all that apply.

2. Looking at old snapshots of family. 3. Participating in a senior citizens program. 4. Visiting the spouse's grave once a month. 5.Decorating a wall with the spouse's pictures and awards received.

The nurse is assessing a client with bladder cancer who had a cystectomy and creation of a ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care?

I empty the urinary collection bag when it is two thirds full. prevents pulling of the appliance and leakage.

The nurse educator is preparing to conduct a teaching session about school-age children regarding the theories of growth and development and plans to discuss Kohlberg's theory of moral development. What information would the nurse include in the session? Select all that apply

2.Moral development progresses in relationship to cognitive development. 3.A person's ability to make moral judgments develops over a period of time. 4.The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. 6.In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain rewards or have favors returned.

The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention, if noted in the plan, indicates the need for revision of the plan?

placing the client in a semiprivate room at the end of the hallway private room with private bath is essential if client has radiation implant.

The nurse in a long-term care facility is observing a nursing student provide foot care to a client with diabetes mellitus. Which action by the nursing student would indicate a need for further teaching?

the nursing student applies lotion to the dorsal and plantar surfaces of the feet and in between the toes. dont apply inbetween the toes because these areas need to be kept dry.

The nurse is teaching a client with a urinary stoma about how to change the collection bag and appliance at home. Which of the following client statements indicates an understanding of the procedure?

the pouch needs to be changed every 5-7 days.

The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse would implement which assessment technique to assess for muscle weakness in the eye?

test the six cardinal positions of gaze.

The surgeon asks the nurse to obtain a urinary catheter that will be used for continuous bladder irrigation. Which urinary catheter would the nurse obtain?

a triple lumen catheter. continuous bladder irrigation/bladder medication instillation.

The nurse is caring for a client with meningitis and implements which transmission-based precaution for this client?

private room or cohort client meningitis is transmitted by droplet infection.

The nurse is performing a neurological assessment on a client and notes a positive Romberg's test. The nurse makes this determination based on which observation?

a significant sway when the client stands erect with feet together, arms at the sides, and the eyes closed. positive romberg is a vestibular neurological sign that is found when a client exhibits a loss of balance when closing eyes.

The nurse is preparing a list of client care activities to be done during the shift. For which clients would the nurse instruct the assistive personnel (AP) to use an electric razor for shaving? Select all that apply

a client with thrombocytopenia. a client receiving an antiplatelet medication.

The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe?

the client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.

The nurse is preparing to teach a prenatal class about fetal circulation. Which statements would be included in the teaching plan? Select all that apply.

the ductus arteriosus allows blood to bypass the fetal lungs. one vein carries oxygenated blood from the placenta to the fetus. two arteries carry deoxygenated blood and waste products away from the fetus to the placenta.

The long-term care nurse is performing assessments on several of the residents. Which are normal age-related physiological changes the nurse would expect to note? Select all that apply.

decline in visual acuity. increased susceptibility to urinary tract infections. increased incidence of awakening after sleep onset.

The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention would the nurse take first?

determine whether there are medication duplications. nurse needs to know what the patient is taking so duplications need to be identified first.

The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse would take which initial action?

activate the emergency response plan specific to the facility

The nurse is instructing a client on how to perform a testicular self-examination (TSE). The nurse would explain that which is the best time to perform this exam?

after a shower or a bath. palpation is easier and client will be able to identify any abnormalities.

The staff nurse is observing a new graduate nurse provide indwelling urinary catheter care to an uncircumcised client. Which action by the new graduate nurse would indicate a need for further teaching?

removes a loose catheter anchor and places a new anchor on the lower leg. needs to be placed on upper thigh not lower leg.

The nurse notes that a 6-year-old child does not recognize that objects exist when the objects are outside of the visual field. Based on this observation, which action would the nurse take?

report the observation to the pediatrician if a 6 yo does not recognize that objects still exist even when outside the visual field, the child is not progressing normally through the developmental stages.

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse would expect to note which finding?

rhythmic respirations with periods of apnea. indicate metabolic dysfunction in cerebral hemisphere/basal ganglia.

The nurse obtains a prescription from a primary health care provider to restrain a client and instructs an assistive personnel (AP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required for the AP?

safely securing the safety device straps to the side rails avoids accidental injury in the event that the side rails are released.

The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site?

serous drainage

The nurse is performing a skin assessment on a client and notes an area of full-thickness loss of skin on the sacrum. Adipose tissue and granulation tissue are present with no visible muscle, tendon, ligament, cartilage, or bone. How would the nurse classify this pressure injury?

stage 3 pressure injury

The nurse is inserting an indwelling urinary catheter in a client. As the nurse begins to inflate the balloon, the client starts to complain of pain. Which action would the nurse take?

stop inflating the balloon, allow saline to drain into the syringe, and advance the catheter farther before reinflating the balloon. pain when inflating the balloon could indicate its in the urethra and not bladder.

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse needs to include which piece of information in discussions with the client?

the best results are achieved when sitting up or with the head of the bed elevated 45-90 degrees. allows for lung expansion

The nurse is teaching a client with right-sided weakness related to a stroke about how to properly ambulate with a cane. Which client action would indicate a need for further teaching?

the client holds the cane on the right side of the body