Exam 2 Practice Questions
What is always the first step of the nursing process?
Assessment
What score on the Braden scale puts the hospitalized patient at risk for skin breakdown?
At 18 or below
An elderly nursing home resident has refused to eat or drink for several days and is admitted to the hospital. The nurse should expect to find which of the following A. Increased blood pressure B. Weak, rapid pulse C. Moist mucous membranes D. Jugular vein distention
B
During shift report, the nurse learns that an older female patient has had several episodes of incontinence when hurrying to the bathroom. Which of the following nursing diagnoses is most likely to apply to this patient? A. Stress urinary incontinence B. Urge urinary incontinence C. Functional urinary incontinence D. Total urinary incontinence
B
Which of the following is the most correctly stated outcome for the Nursing DX: Ineffective airway clearance r/t thick mucus secretions? A. Airway clearance will be effective B. Will turn, cough, deep breathe q 2 hours C. Intake of 3000 ml of fluid per day D. Lungs CTA
D
A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client which should the nurse interpret as a need to postpone the session?
Pain
Sexualiaty PLISSIT?
Permission Limited Information, Specific Suggestions, Intensive Therapy
A nurse is completing the 8-hr I&O record for a client who consumed 4 oz of clear soda, 1 piece of toast, 12 oz of water, 1 cup of fruit-flavored gelatin, and 1/2 cup of chicken broth. The client also received 300 mL of 0.9% sodium chloride IV. The nurse should record how many mL of intae on the client record?
1140
What is the pound lifting limit per nurse?
35 pounds
Fowler's positions
45° elevation of the upper body, knees may be flexed
What is a normal fasting blood glucose?
70-110
A nurse is assisting an older adult client who sometimes loses her balance while walking. Which of the following devices should the nurse use when helping the client's ambulate?
gait belt
What is the normal range for hydration in an adult?
1,500-2,500 mL/day
Name the 6 positions discussed in the mobility handout.
1. Fowler's position 2. Semi-Fowler's 3. Dorsal recumbent (supine) 4. Prone 5. Lateral 6. Sim's
Rem sleep is what percent of the night?
25%
A nurse is calculating a client's fluid output for a 12-hr period. It includes Jackson-Pratt (JP) drainage 35mL, NG suction 120 mL, and incontinence pads weighing 240 g, 275 g, 310 g, and 270 g. The dry weight of the incontinence pads i 90g. The nurse should record how many mL of output on the client's record? (1g=1mL)
890 mL
What is a normal oxygen level?
96
A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?
Apply a moisture barrier ointment to the client's skin
What is an appropriate outcome statement for a client with the diagnosis of disturbed body image related to amputation of left lower leg secondary to diabetes.
Client will state they accept the changes in their body
A nurse is providing dietary teaching for a client who is Asian-American and is gazing at the floor during the instructions. Which of the following actions should the nurse take to demonstrate culturally sensitive nursing care?
Continue with the discussion
A nurse is caring for a client who has bilateral eye patches in place following an injury. When the client's food tray arrives, which of the following interventions should the nurse take to promote independence in eating?
Describe the client the location of the food on the tray
A nurse is preparing to transfer a client from a bed to a chair. Which of the following actions should the nurse take first?
Determine if the client can bear weight
A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse preform first.
Determine the location of the pain
While assisting the client with a bath, the nurse encourages full range of motion in all the client's joints. Which activity would best support range of motion in the hand and arm?
Have the client brush hair and teeth
What are some non pharmacological management of discomfort?
Heat, ice, massage, acupressure, immobilization, positioning, hygiene, TENS, distracting, hypnosis guide imagery, music, biofeedback
Hypervolemia vs Hypovolemia?
Hyper: excess fluid volume Hypo: fluid volume deficit
A nurse is instructing a young adult client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further teaching?
I watch television until I fall asleep at night
A nurse is teaching a client who reports insomnia about promoting rest and sleep. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
I will no longer have a glass of wine before bedtime
Name 2 nursing interventions to treat/prevent atelectasis (the collapse of part or all of a lung)
Incentive spirometry Cough and deep breathe
What food are included in a full liquid diet? A. Jello B. Strained cream soup C. Ice cream D. Pureed carrots E. Mashed potatoes F. Pudding
Jello, strained cream soup, ice cream, pudding
A patient has not voided since your shift started at 7am. The night nurse stated that the patient voided at 6 am right before you came in. The patient voids at noon and it measures to be 180ml. Is there a problem with the patient's elimination?
No
A nurse is filling out an incident report after finding a client lying on the floor. Which of the following information should the nurse include?
The client was lying on the floor next to his bed
What is pain threshold?
amount of stimulation necessary to feel pain
Dorsal recumbent position
head elevated on small pillow
Sims positions
semi prone
What nursing interventions should be implemented for a client with a nursing diagnosis of disturbed sleep pattern? Name 3.
1. Encourage client to establish a bedtime routine and aregular sleep pattern. 2. Instruct client to avoid caffeine and nicotine a bedtime. 3. Adjust environment; have patient control noise,temperature, and light in the bedroom. 4. Teach patient how to perform muscle relaxation before bedtime; include demonstration. 5. Instruct client to avoid heavy meals before bedtime. 6. Instruct client to get out of bed and engage in quiet activity if they can't sleep in 30 minutes
Semi-Fowler's position
15 to 45° elevation of upper body
Acute vs chronic pain?
Acute- less than 6 months Chronic- more than 6 months
A nurse is caring for a client who is 1 day postoperative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first?
Ask the client to rate her pain on a scale form 0-10
What is the first thing a nurse should do before implementing any action?
Assess the client
What are the first steps of the nursing process?
Assessment
FLACC pain scale?
F: Faces. L: Legs. A: Activity. C: Cry C: Consolability
What important assessment information is required for the nursing diagnosis ineffective gas exchange?
Pulse oximetry
What important steps are needed to evaluate the patient's goals or projected outcomes?
Reassess
What is ineffective airway clearance?
Reduced ability to clear secretions or obstructions for the respiratory tract to maintain a clear airway
A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure?
Surgeon
True or False: The nursing diagnosis activity intolerance can be used for other medical issues outside of oxygenation.
True
Lateral position
side-lying
A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following?
urinary tract infection
What is the most effective method of assessing fluid loss?
Daily weights
A nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse take?
Explain to the client what is about to happen
1. An 89 year old states, "I am a lost cause. I can't even stand long enough to cook my own meals anymore." Which of the following is the most appropriate response?
"That must be difficult. What things are you still able to do?
Name and describe the 4 nursing diagnostic categories related to oxygenation we discussed in class.
1. Ineffective airway clearance 2. Decreased Activity Tolerance/Activity intolerance 3. Ineffective breathing pattern 4. Impaired gas exchange
A nurse is calculating the total fluid intake for a client during a 4-hr period. The client consumes 1 cup of coffee, 4 oz of orange juice, 3 oz of water, 1 cup of flavored gelatin, 1 cup of tea, 5 oz of broth, and 3 oz of water. The nurse should record how many mL of intake on the client's record.
1170
You are recording I&O for Mr. Green at 3 PM. He was NPO for breakfast. At lunch he had ½ cup of jello, a bowl of soup (6 ounces) & a can of soda (12 Ounces). He drank 1 cup of water after lunch. He had 800 ml of IV fluids. What was his intake on your shift?
1700
What is the maximum number of pounds a nurse should lift alone?
25 lbs
A nurse is reviewing the labratory results of a client who is dehydrated. Which of the following BUN lab values should the nurse report to the provider?
25mg/dL
Vital signs should return to normal within how many minutes of activity?
3 minutes
You are recording I&O for Mr. Green at 3 PM. During your shift he vomited 250 ml of yellow liquid, had a liquid stool that measured 100 ml and voided 3 times—150 ml, 200 ml and 100 ml. What was his output on your shift?
800
Using the Braden Scale what score places a patient at high risk for skin breakdown?
<18
A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend? A. Grape and walnut chicken salad sandwich on whole wheat bread B. Broccoli and cheese soup with potato bread C. Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing D. Turkey and mashed potatoes with brown gravy
A
Chronic Pain is more likely to A. cause parasympathetic symptoms B. occur for 3 months C. be stabbing in quality D. be felt as phantom pain
A
The patient has a nursing diagnosis of risk for constipation related to immobility and decreased fluid intake. Which of the following is the appropriately stated projected outcome for this diagnosis? A. Patient will have a bowel movement every other day. B. Patient will drink 2000 ml of fluid every day C. Patient will not be constipated D.Patient will be turned every 2 hours
A
When caring for a patient with urinary retention, the nurse would anticipate an order for
A urinary catheter.
Before transferring a patient from the bed to a stretcher, which assessment data does the nurse need to gather? (Select all that apply.) A. Patient's weight B. Patient's level of cooperation C. Patient's ability to assist D. Presence of medical equipment E. Nutritional intake
A, B, C, D
The effects of immobility on the cardiac system include which of the following? (Select all that apply.) A. Thrombus formation B. Increased cardiac workload C. Increased apical pulse D. Increased capillary refill E. Orthostatic hypotension
A, B, C, E
The nurse is caring for a patient in the sleep lab. The nurse recognizes that the patient is in stage 4 REM from which of the following assessments? (Select all that apply). A. Irregular respirations. B. Fluctuating blood pressure. C. The patient is difficult to awaken. D. Eyes rapidly move.
A, B, D
Which of the following promotes normal defecation? Select all that apply A. Providing privacy for defecation B. Fluid intake of 2000ml/day C. Use of laxatives D. Ignoring the duodenocolic reflex E. Walking 10,000 steps per day
A, B, E
The patient is asking the nurse about the best way to stay healthy. The nurse explains to the patient that from a nutritional point of view, the patient should (Select all that apply.) A. Maintain body weight in a healthy range. B. Increase physical activity. C. Increase intake of meat and other high-protein foods. D. Keep saturated fat intake to 10% or less. E. Choose and prepare foods with little salt.
A, D, E
Sally is 5'7", weighs 105 pounds and believes she is fat. Which of the following most represents this perception?
Altered body image
The nurse is gathering a history from a 72-year-old male patient being admitted to a nursing home. The patient requests a private room. The nurse understands that A. The patient cannot be sexually active since he is moving into a nursing home. B. The patient may be requesting a private room to facilitate an intimate relationship with his partner. C. There is no need to take a sexual history since most older adults are uncomfortable discussing intimate details of their lives. D. Older adults in nursing homes usually do not participate in sexual activity.
B
The nurse is performing an assessment of an immobilized client Which of the following causes them to take action? A. Heart rate of 88 B. Reddened area on sacrum C. Nonproductive cough D. Voiding clear yellow urine
B
The nurse recognizes that which of the following is a modifiable contributor to a patient's perception of pain? A. Age and gender B. Anxiety and fear C. Culture D. Previous pain experience
B
Which of the following clients may be exhibiting signs of a poor nutritional status? A. Billy White, whose hair is shiny and neither dry or oily. B. Nella Green, whose skin is dry & rough with a few bruises. C. Mrs. Black, whose tongue and mucous membranes are pink and moist. D. Mr. Brown, whose albumin level is 4.2 g/dl.
B
Which of the following substances will promote normal sleep patterns? A. Caffeine B. L-Tryptophan C. Narcotics D. Alcohol
B
Which of the following are allowed on a full liquid diet? Select all that apply. A. Scrambled eggs B. Chocolate pudding C. Tomato juice D. Mashed potatoes E. Cream of Wheat cereal
B, C, E
In taking the client's health history it is important that the nurse A. Discuss sexual concerns only if the client brings them up. B. Uses emotionally laden terms when discussing sexual concerns. C. Focuses only on physical factors that affect sexual functioning. D. Routinely includes a few questions related to sexual functioning.
D
A patient is experiencing oliguria. Which action should the nurse perform first? A. Increase the patient's intravenous fluid rate. B. Encourage the patient to drink caffeinated beverages. C. Assess for bladder distention. D. Request an order for diuretics.
C
The nurse is buys and needs to delegate a task to a nurse assistant. Which task is appropriate to delegate? A. Give a medication B. Give a bath to an unstable patient C. Obtain vital signs on a stable patient D. Ask the patient if their pain medication is working
C
Which of following is a correctly stated nursing diagnosis for the client with an alteration in fluid & electrolyte status? A. Deficient fluid volume r/t NPO status B. Excess fluid volume r/t heart failure C. Deficient fluid volume r/t difficulty swallowing D. Excess fluid volume r/t physician ordering too many IV fluids.
C
Which of the following is a false statement about pain? A. Pain occurs when the person experiencing it says it does. B. Pain is produced by tissue injury. C. Pain produces the same reactions in all persons. D. Pain tolerance can change.
C
Which of the following should be included in teaching a female client health promotion measures regarding urinary elimination? A. If your urine becomes cloudy or has blood in it, increase your fluid intake B. After urination wipe from the anus toward the urinary meatus C. To strengthen sphincter muscles, do not void when you feel the urge, wait as long as you can. D. Empty the bladder at each voiding.
D
Which statement best reflects the nurse's assessment of the fifth vital sign? A. "Do you have any complaints?" B. "Are you having any discomfort right now?" C. "Is there any thing I can do for you now?" D. "Do you have any complaints of pain?"
D
Which statement made by a parent of a 2-month-old infant requires further education? A. I'll continue to use formula for the baby until he is a least a year old. B. I'll make sure that I purchase iron-fortified formula. C. I'll start feeding the baby cereal at 6 months. D. I'm going to alternate formula with whole milk starting next month.
D
Mrs. G, a 42 year old Mexican-American patient, refuses to eat the hospital prepared food and eats only the flour tortillas, beans and rice brought in by her family. The nurse's first action should be to
Determine whether Mrs. G's diet meets her daily nutritional needs.
A nurse is assessing a client who has insomnia. Which of the following questions is the highest priority for the nurse to ask the client?
Do you have difficulty staying awake when you are driving
True or False: A nursing diagnosis is the same as a medical diagnosis?
False
True or False: High Fowler's position is a great position for someone with risk for skin breakdown
False
True or false: Risk for diagnosis have 3 parts. Problem, etiology, and cues.
False
What is the appropriate nursing diagnosis for a client with a urine specific gravity of 1.1?
Fluid volume deficit (hypovolemia)
What would be an appropriate intervention for someone with impaired gas exchange related to pain?
Give them a heat or ice pack
When asked to describe herself, a client with newly a diagnosed chronic illness describes only those roles involving others (e. g. wife, mother, medical assistant) and no personal hobbies or interests. In planning her care the nurse should include which of the following?
How her treatment will affect her ability to perform those roles.
Identify the problem in this statement? Impaired gas exchange r/t pain AMB shallow breaths and oxygen of 89%.
Impaired gas exchange
What is ineffective breathing pattern?
Inspiration and /or expiration that does not provide adequate ventilation.
What is decreased activity tolerance/activity intolerance?
Insufficient endurance to complete required or desired daily activities.
How can I identify what the cues or defining characteristics are in the nursing dx statement?
It's followed by AMB
What consist of a clear liquid diet?
Liquid, see through at room temp
What are the normal hemoglobin values for men and women?
Men: 14-18 Women 12-16
A man brings his elderly wife to the emergency department. He states that she has been vomiting and has had diarrhea for the past 2 days. She appears lethargic and is complaining of leg cramps. What should the nurse plan to do first?
Obtain blood for serum electrolytes
When weighing the client with a nursing diagnosis of fluid volume excess, the nurse should weigh the client?
On the same scale each day
4. Which of the following is an appropriately stated projected outcome for the nursing diagnosis: Risk for ineffective sexuality patterns related to altered self concept 2° mastectomy.
Patient will verbalize satisfaction with sexual functioning
Your patient has the nursing diagnosis: Acute pain related to surgical incision and muscle spasms secondary to repair of fractured hip. Which of the following is the best projected outcome statement? By discharge the patient will
Rate pain as a 1-2 on a 0-10 scale.
A depressed patient is crying and verbalizes feelings of low self-esteem and self-worth such as, "I'm such a failure ... I can't do anything right." What is the nurse's best response?
Remain with the patient until he or she validates feeling more stable.
3. Because of significant concerns about financial problems a middle aged client complains of difficulty sleeping. Which of the following would be an appropriate outcome for the nursing diagnosis, Insomnia related to anxiety response secondary to financial concerns AMB difficulty falling asleep, c/o fatigue on awakening? By day 5, Mr. D will
Report falling asleep within 20-30 minutes
What does the Braden Scale evaluate?
Risk factors that place the patient at risk for skin breakdown
A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain.
Self-report of the pain
What are the cues/defining characteristics in impaired gas exchange r/t pain AMB shallow breaths and oxygen of 89%.
Shallow breaths, oxygen 89%
What does etiology mean?
The cause of the problem
When developing nursing interventions, what should the nurse look at to begin to make their plan?
The cause of the problem
A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which of the following is most important for the nurse to determine?
The client's current weight-bearing status
A nurse is caring for a client who is post-op. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of a client's pain.
The client's self-report of pain severity
4. The nurse is caring for a young adult patient on the medical-surgical unit. When doing midnight checks, she sees that the patient is awake and is doing a puzzle. What is the best explanation for the patient being awake?
The patient's sleep-wake cycle preference is late evening.
Which of the following nursing interventions should be implemented to maintain a patent airway in a patient on bed rest?
Use of incentive spirometer every 1-2 hours while awake
In teaching methods to promote sleep habits at home, the nurse instructs the client to
Use the bedroom only for sleep or sexual activity
Soft diet?
soft in texture, low in residue, easily digested Mechanical soft: easily chewed Pureed: consistency of baby food
What consists of a full liquid diet?
liquid at room temp
Prone position
on abdomen with head turned to side
Identify the etiology in this statement. Impaired gas exchange r/t pain AMB shallow breaths and oxygen of 89%
pain
Name the 5 rights of delegation
1. right task 2. to the right person 3. in the right position 4. with the right communication 5. performing the right evaluation
A nurse is calculating a client's intake and output for an 8-hr shift. The client's intake included 1,000 mL 0.9% sodium chloride IV, one 6 oz cup of coffee, 6 oz of water, one 180mL bowl of soup; 3 oz of flavored gelatin, and 3 oz of ice cream. How many mL should the nurse document as the clients total intake for the shift.
1720
A nurse is caring for an older adult client. The nurse should recognize the client is at risk for which of the following physiological changes. (Select all that apply.) A. Decreased gastric motility B. Decreased skin elasticity C. Increased pain threshold D. Increased metabolic rate E. Increased cardiac output
A, B, C
What is the best way to weight a patient? (Select all that apply.) A. Same time everyday B. Same clothes everyday C. Same scale everyday D. Same location everyday
A, B, C
A nurse is planning care for a hospitalized client who is immobile and in a continuous mitten restraint. Which of the following interventions should be included in the client's care plan? A. Document restraint checks and client status every 2 hours B. Educate the client's family about restraint use C. Obtain the provider's prescription renewal every 72 hours D. Implement passive range-of-motion exercises. E. Release the restraint and reposition the client every 4 hours.
A, B, D
Which of the following are appropriate interventions to increase airway clearance? Select all that apply. A. Perform Chest PT as ordered B. Teach patient controlled coughing C. Encourage the client to stay in bed until her strength returns. D. Increase fluid intake to 2500 ml/ day E. Encourage patient to use incentive spirometer once a day
A, B, D, E
A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select all that apply) A. Contractures of the Extremities B. Polyuria C. Diarrhea D. Crackles in the lungs E. Pressure Ulcers
A, D, E
What nursing diagnosis are correctly states? (Select all that apply.) A. Risk for constipation r/t immobility B. Risk for injury r/t lack of side rails on bed C. Pain and anxiety r/t surgery D. Spiritual distress r/t atheisms E. Impaired skin integrity r/t heel pressure and rubbing on the sheets amb 1 cm blister on heel
A, E
Which of the following are not hazards of immobility? A. Increased digestion B. Decreased hemoglobin levels C. Increased muscle mass D. Pressure injuries E. Increased lung expansion
A,C,E
Which of the following would be an appropriate goal for the diagnosis of impaired physical mobility: A. Improved mobility B. Able to ambulate 5 feet with walker C. Assist client from bed to chair tid D. Physical therapist will assess client's mobility
A. Improved mobility
Formulate a nursing diagnosis for a client post knee replacement surgery. The client rates their pain level as 8/10, grimaces while changing positions, and states they can not get comfortable.
Acute pain related to surgical incision secondary toknee replacement surgery AMB client rating pain8/10, grimacing while changing positions, and states they can not get comfortable.
The patient has a pulse oximetry reading of 88% on room air. Based on this information alone you would hypothesize that the most likely nursing diagnosis for this patient is A. Activity intolerance B. Impaired gas exchange C. Ineffective airway clearance D. Ineffective breathing patterns
B
What is the projected outcome in this sentence? A. Patient will have decreased pain B. Patient is no longer groaning in pain C. Patient will take a prescribed pain medication D. Patient will use a heating pad for pain relief
B
Which of the following are physiological effects of exercise on the body systems? Select all that apply. A. Decreased cardiac output B. Increased respiratory rate and depth C. Increased muscle tone, size and strength D. Change in metabolic rate
B, C, D
Identify the correctly stated outcome statements. A. Consult the respiratory therapist. B. The client's oxygenation saturation will be above 95%. C. Apply oxygen per nasal canula for oxygen saturation less than 95%. D. Respirations will be between 16-20 breaths perminute. E. The client's oxygen saturation was 99% on room air.
B, D
Which of the following areas of the body provides the best site to determine cyanosis in a person with dark skin?
Beds of fingernails and mucous membranes of the mouth
Which of the following observations by the nurse may indicate an alteration in the oxygenation status of the client? A. Neck veins are flat B. Chest expansion is symmetrical C. Needing to sit up to breathe D. Even unlabored respirations
C
All of the following are oxygen delivery methods. Place in order from that which can deliver the highest oxygen concentration to the method that provides the lowest O2 concentration A. Face mask B. Nasal canula C. Non-rebreather mask D. Partial rebreather mask
C, D, A, B
Which of the following is a principle of proper body mechanics when lifting or carrying objects? (Select all that apply.) A. Keep the knees in a locked position. B. Bend at the waist to maintain a center of gravity. C. Maintain a wide base of support. D. Hold objects away from the body for improved leverage. E. Encourage patient to help as much as possible.
C, E
A nursing assistive personnel asks for help to transfer a patient who is 125 lbs (56.8 kg) from the bed to a wheelchair. The patient is unable to help. What is the nurse's best response?
Call the lift team for additional assistance
Which of the following is a correctly stated nursing diagnosis? A. Constipation related to surgery B. Risk for impaired gas exchange related to fluid in lungssecondary to pneumonia AMB oxygen saturation 90% on room air and crackles in lungs. C. Disturbed sleep pattern related to clients' poor choices and refusal to establish a bedtime routine. D. Acute pain related to tissue injury secondary to abdominal surgery ABM client rating pain 8/10 and states "I just can't get comfortable and rest"
D
The client has a nursing diagnosis of risk for constipation related to immobility and decreased fluid intake. Which of the following are appropriate interventions for this diagnosis?
Encourage client to increase po fluids Assist client to ambulate in hall twice daily
A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions?
Encourage the client to increase fluid intake
A client received pain medication one hour ago. They tell the nurse their pain score has decreased from a 7 to a 3. Which stage of the nursing process is the nurse performing?
Evaluation
The nurse recognizes that the older adult's progressive loss of total bone mass and tendency to take smaller steps with feet kept closer together will most likely
Increase the patient's risk for falls and injuries
A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?
Lock the wheel of the bed and the wheelchair
A nurse is caring for a client who has schizophrenia and is having difficulty with performing ADLs. The nurse should consult with which of the following members of the interdisciplinary team to assist the client?
Occupational Therapist
A nurse is reviewing a client's lab results. Which of the following lab values should the nurse report to the provider.
Sodium 126 mEq/L
A nurse in a long-term care facility is caring for an older client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior?
Take the client to the bathroom every 2 hours
What is the correctly stated projected outcome for the following diagnosis? Impaired physical mobility r/t inflammation of right knee AMB inability to bear weight on right leg.
Walk length of hall with crutches by the end of the week
A nurse is assisting an older adult client who is sedentary plan a new exercise regimen. Which of the following activities should the nurse recommend.
Walking
Which of the following is the most correctly states outcome for the Nursing DX: Ineffective breathing pattern r/t acute pain secondary to chest trauma.
Will maintain a breathing pattern with respiratory rate 16-20 and normal depth
What is the Braden Scale?
an evidence-based tool that looks at various factors that put patients at risk for developing a pressure ulcer. Includes: sensory perception moisture activity mobility nutrition friction shear (1-4)
What is pain reaction?
autonomic responses to pain, influenced by past experience, culture, mood, attitudes, emotions, and environment
What is impaired gas exchange?
excess or deficit in oxygenation and/or carbon dioxide elimination
A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider?
output of 175 mL in the past 8 hours
