Exam 3

A client is scheduled for a CABG procedure. What information should the nurse provide to the client?

"A coronary artery bypass graft will benefit your heart."

Which documentation example best reflects the complexity of client teaching by the nurse?

"Client and spouse taught how to use phone app to count carbohydrates; client return demonstrated carb counting for a hypothetical meal."

The clinic nurse is obtaining demographic data from a client. The client states, "Why do you need to know what my ethnicity is?" How should the nurse respond?

"Collecting this information allows us to develop a personalized plan of care to meet your needs."

the nurse has just attended a seminar on concepts of cultural diversity. Which statement made by the nurse would require further education?

"Culture cannot be influenced, and you are born with your culture."

In a nursing unit, the RN delegates nursing tasks to the nursing assistant. Keeping in mind the delegation guidelines, which of the following statements denotes the right direction for the nursing assistant?

"Dispose of the disconnected IV set."

A nurse is caring for a female client of Hawaiian descent. Which interview question would be appropriate based on the cultural beliefs of Hawaiians?

"Do you use any medicinal plants or minerals?"

The student nurse asks, "what is interstitial fluid?" What is the appropriate nursing response?

"Fluid in the tissue space between and around cells."

A nurse is asking a colleague about a situation. Which statement demonstrates assertive communication?

"I think there is a better way to handle this.

A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate?

"Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein."

The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response?

"Let me refer you to the blood bank so they can provide you with information."

What is the rate of administration for packed red blood cells?

1 unit over 2 to 3 hours, no longer than 4 hours

A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL?

3,000

A nurse is assessing the central venous pressure of a client who has a fluid imbalance. Which reading would the nurse interpret as suggesting an ECF volume deficit?

3.5 cm H2O

A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate?

50 gtt/min

The nurse works at an agency that automatically places certain clients on intake and output (I&O). For which client will the nurse document all I&O

55-year old with congestive heart failure on furosemide

A physician has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing?

60 drops/mL

The nurse is calculating an infusion rate for the following order: Infuse 1000 ml of 0.9% Na Cl over 12 hours using an electronic infusion device. What is the infusion rate?

83 ml/hr

A Catholic priest baptizes a stillborn baby of a Catholic family. What type of practice is this considered?

A ritual

A client made a formal request to review his or her medical records. With review, the client believes there are errors within the medical record. What is the most appropriate nursing response?

According to HIPAA legislation, you have a right to request changes to inaccurate information."

The new graduate nurse is having difficulty managing the time required to care for a group of complex clients and is several hours behind in completing nursing interventions. Of the following outstanding tasks, which nursing intervention should the nurse complete first?

Administer a dose of digoxin (lanoxin) that is two hours behind schedule.

What is the lab test commonly used in the assessment and treatment of acid-base balance?

Arterial blood gas

The nurse is assessing an older adult of Asian decent who immigrated at the age of 3 years. The client speaks the dominant language and lives in a predominantly Asian neighborhood. Which action by the nurse is most appropriate?

Ask the client about special cultural beliefs or practices.

When caring for a client at the health care facility, the nurse observes that the client is having difficulty understanding the health education. Which action is most appropriate?

Assess for cultural differences.

After a nurse manager implements a solution to the problem of delays in obtaining supplies, the first task for the manager is to

Assess whether the desired results have occurred

A client from Malaysia is admitted to the health care facility with reports of cramping pain in the abdomen and loose stools. Where should the nurse be seated when interviewing the client?

At more than one arm's distance

Which scenario is an example of cultural competence in nursing?

Attending a conference for cultural diversity

A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client?

Avoid salty or excessively sweet fluids.

Which behavior by the nurse is stereotyping?

Avoiding older adult clients because their care is time consuming

The nurse is caring for a 60-year-old client with an improper bowel movement regimen. Which of the following is the most appropriate method the nurse should use to conduct new learning?

Begin the session with a reference to the client's actual experience.

The nurse is working at a facility that is applying for Magnet® Recognition. The nurse recognizes that research supports Magnet® hospitals as having which direct effect on client care?

Better patient outcomes

A nurse is educating a 4-year-old client about cast care following a tibia-fibula fracture. Which action is not developmentally appropriate to include in the nurse's education?

Blocking 30 minutes of time for skill teaching

COPE model

C - creativity O - optimism P - planning E - expert information

The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level?

Cardiac dysrhythmias

The nurse is caring for older adult clients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these clients?

Cardiac volume intolerance

A nurse is conducting a cultural assessment of a client. Which person would the nurse identify as the expert?

Client

The nurse manager for the psychiatric unit sees that there are major conflicts between the day and night shift staff. The nurse manager suggests that each shift put aside their differences for a time and determine a common major goal. Which of the following conflict resolution styles does the nurse manager display?

Collaborating

A student nurse is attempting to improve their communication skills. Which therapeutic communication skill is appropriate?

Control the tone of the voice to avoid hidden messages.

A client originally from Asia believes that her illness is caused by an imbalance of yin and yang. The nurse states, "You can call it whatever you believe, but you have a metabolic disorder." What is this nurse demonstrating?

Cultural blindness

A staff nurse meets with the charge nurse and is reporting that all the new nurses are leaving messes on the unit. The staff nurse states, "These youngsters think they can waltz in here and get our jobs." What is this nurse demonstrating?

Cultural conflict

A client is admitted with end stage pancreatic cancer and is experiencing extreme pain. The client asks the nurse if an acupuncturist can come to the hospital to help manage the pain. The nurse states, "You won't need acupuncture. We have pain medications." Which characteristic has the nurse displayed?

Cultural imposition

problem-oriented medical record (POMR)

Database, problem list, care plan, and progress notes, SOAP format

A nurse reads a complete blood count report for a patient who has been admitted to the hospital with fluid overload from late stage kidney disease. What abnormal result would the nurse expect to find?

Decreased hematocrit

The nurse is working to enhance time management skills and has to administer pain medications to several patients, obtain vital signs, and assist clients with bathing. What should the nurse do next? You Selected:

Delegate bathing and vital signs tasks

The nurse has recently been promoted to nurse manager on a pediatric unit and has decided to accept input from staff regarding changes they would like to see on the unit. Which type of leadership style is the nurse embodying?

Democratic

The nurse manager who asks staff members to give suggestions on how to improve collaboration between nurses and physicians is exhibiting what style of leadership?

Democratic

A nurse informs the client that he has no choice and must take his bath in the morning. What type of leadership does this exemplify?

Directive leadership

A nurse inspecting the IV site of a client notices signs of phlebitis (inflammation). What would be the appropriate nursing intervention for this situation?

Discontinue the IV and relocate it to another spot.

Considered cultural norms of the healthcare system

Documentation and jargon Deference to pecking order Procedures for birth and death Problem solving

The nurse needs to understand the teaching-learning process when administering

Educational interventions

The nurse manager is assisting the hospital to meet requirements for Magnet® recognition. Which measure should the nurse manager recognize as being a requirement for this recognition?

Encouraging reporting of errors or potential errors without fear of punishment

The nurse manager is concerned about the large number of teenage mothers being seen in the obstetrics clinic. How can the nurse manager use the transformational leadership style to address the concern?

Enlist volunteers to help develop a community outreach project that will educate teenagers on methods to prevent pregnancy

A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV?

Ensure that the prescribed solution is clear and transparent.

Which of the following attributes would be characteristic of a nurse mentor? Select all that apply

Experienced licensed professional Demonstrates leadership abilities Resourceful Supportive

Which of the following statements is an appropriate nursing diagnosis for an client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion?

Extracellular Volume Excess related to heart failure, as evidenced by edema and orthopnea

A nurse is caring for an older adult client with arthritis. Which action is the priority for the nurse when conducting the health education for the client?

Find out what the client wants to know.

A nurse is measuring intake and output for a client who has congestive heart failure. What does not need to be recorded?

Fruit consumption

A nursing facility has recently implemented new policies regarding nurse-to-patient ratios. The nursing staff seems very resistant to the change. How can the nurse manager help the staff accept the change?

Hold a unit meeting to discuss how the changes will benefit staff.

The nurse uses the acronym TEACH when planning care for clients on a busy hospital ward. Which intervention accurately represents an aspect of this acronym? Select all that apply.

H—The nurse honors the client as a partner in the education process. A—The nurse acts on every teaching moment. C—The nurse clarifies often.

Which statement is not true regarding a medication administration record (MAR)?

If the client refuses the dose you don't have to document this on the MAR.

When providing client education it is essential for the nurse to incorporate what action so that learning can be optimized?

Include educational strategies that encourage clients to be active participants.

A patient has metabolic (non respiratory) acidosis. What type of respiration's would be assessed?

Increased depth and rate

Which developmental consideration is a nurse assessing when determining that an 8-year-old boy is not equipped to understand the scientific explanation of his disease?

Intellectual development

The nurse, along with a nursing student, is caring for Mrs. Roper, who was admitted with dehydration. The student asks the nurse where most of the body fluid is located. The nurse should answer with which fluid compartment?

Intracellular

Which teaching statement best exemplifies cultural competence in relation to time for the American culture?

It is important to be on time for your health care appointment.

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation?

It provides quick access to abnormal findings.

A staff nurse works on a surgical unit where the nurse leader allows the staff to make all decisions and direct themselves. The staff nurses fill out the work schedule and sometimes there are days where the unit is short staffed. The staff nurse feels the unit needs better leadership. The nurse leader is practicing which of the following leadership styles?

Laissez-Faire

Karen Wolf, RN, is the charge nurse on the orthopedic unit. She believes in giving the staff as much power as possible. The nurses are allowed, among other things, to create their own work schedules, provide dates and times for unit meetings, and create the agendas, to which Karen contributes. Karen's style of leadership can be described as which of the following?

Laissez-faire

The nurse manager calls a staff into a unit meeting to discuss patient satisfaction. During the meeting, several staff members assume control. The nurse manager does not intervene to regain control of the group. Which type of leadership style is the nurse embodying?

Laissez-faire

Which nursing action displays linguistic competence?

Learning pertinent words and phrases in the client's language

Primary purpose of an incident report

Means of identifying risks

A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)?

Metabolic alkalosis

A nurse is documenting information a lousy a patient in a long term care facility. What is used in a Medicare certified facility as a comprehensive assessment and as the foundation for the RAI?

Minimum data set

Mr. Jones is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations should the nurse be alert?

Muscle weakness, fatigue, and dysrhythmias

Which client has more extracellular fluid?

Newborn Newborns have more extracellular fluid than intracellular fluid.

A client with Asian heritage is admitted to the unit. What cultural assessment might the nurse anticipate?

Nonverbal expressions of pain

The nurse is caring for a client whose blood type is B negative. Which donor blood type does the nurse confirm as compatible for this client?

O neg

A nurse on a telemetry unit is admitting a client and has an unlicensed assistive person (UAP) helping with the admission process. Which task can the nurse delegate to the UAP?

Obtaining an admission weight for the client utilizing the client's bed scale

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.

A nurse manager has asked staff to create a plan to improve patient outcomes. In the past, the staff have not met deadlines. How can the nurse manager use transactional leadership style to ensure the deadline is met?

Offer two days paid vacation

When caring for a psychiatric client, a formal contract is made with the client during which phase of the nurse-client relationship?

Orientation phase

A nurse reads the laboratory report for a patient and notes that the patient has hyponatremia. What physical assessment would be made?

Palpate skin of sternum

A client with a body mass index of 40.3 kg/m2 states, "I know I need to get rid of this fat. I just don't know how." Which is the best assessment for the nurse to make at this time?

Past interventions for weight loss

The most likely candidate for total parenteral nutrition is the client:

Patient with severe pancreatitis

Which of the following information would a nurse include as part of a minimum data set when using electronic medical records? Select all that apply.

Patient's sex Admission date Insurance Ethnicity

According to Rosenstock, which of the following are heath beliefs critical for patient motivation? Select all that apply.

Patients view themselves as susceptible to the disease in question Patients view the disease as a serious threat Patients believe there are actions they can take to reduce the probability of contracting the disease

An active, otherwise healthy, older adult client presents to the clinic with severe osteoarthritis in the bilateral knees. The nurse knows this client does not want to be a burden on his family, and he remains stoic even though he reports the pain as severe. He avoids the topic of surgery and attends church weekly. His family is supportive of any decisions he makes regarding his health. Which of the assessment data are most important to forming an individualized education plan for this client concerning treatment for his osteoarthritis?

Personal perception of health and aging

The nurses at a health care facility were informed of the change to organize the clients' records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records?

Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.

Functions of water

Provide a medium for transporting substances throughout the body Facilitate cellular metabolism and proper chemical functioning Maintains normal body temperature Facilitate digestion and promote elimination

Which strategy should the nurse use when providing education to the older adult client?

Remain calm and conduct the teaching session in a quiet environment.

A nurse is assigned to care for a client who speaks Turkish. Which action by the nurse would be most effective when providing care for this client?

Requesting the assistance of a trained interpreter

The nurse overhears a colleague state, "All people from that client's country are rude." What is the appropriate nursing response?

Respond by saying, "Stereotypes keep us from accepting others as unique individuals."

A nurse manager best demonstrates effective leadership characteristic by which action?

Sharing a vision for the unit and enlisting support

A nurse may attempt to help a client solve a situational crisis during what type of counseling session?

Short-term counseling

In what type of documentation method would a nurse document narrative notes in a nursing section?

Source oriented record

A client is reluctant to learn to do finger sticks for home INR monitoring. What is the best statement by the nurse?

Tell me what you know about these tests.

A client reports pain at his IV insertion site. The nurse assesses the site and suspects phlebitis based on which assessment findings? Select all that apply.

The IV solution is infusing sluggishly. The vein feels cordlike on palpation.

A charge nurse on a medical-surgical unit is asked by the nurse manager to serve as a mentor to another staff nurse who is less experienced. Which of these would best describe this role?

The charge nurse is providing support for the staff nurse in new responsibilities.

The nurse is advising a client about health problems related to being overweight. The client acknowledges the need to lose weight. The nurse provides education on how to count calories in food and the importance of daily exercise. The client states she will begin to count caloric intake beginning with the next meal. The client also states intentions to begin an exercise program with friends. Which statement illustrates Lewin's stage of unfreezing?

The client acknowledges the need to lose weight

A Chinese client who was previously treated at the health care facility for an open wound has been admitted again because the wound has become gangrenous. It has been identified that the client failed to understand proper wound care. What is the probable reason for the client failing to understand the instruction?

The client belongs to a different culture.

The case manager works in a facility that supports a participative leadership style. Which of the following should the nurse recognize as an example of democratic leadership style?

The interdisciplinary health care team collectively developing plans of care for clients

The nurse recognizes that a new mother is having difficulty breastfeeding her baby. The nurse provides assistance by demonstrating various positions to hold the baby while feeding. The nurse also educates the mother on ways to ensure proper latching. The new mother attempts to breastfeed the baby again using the new techniques and is successful. Which statement illustrates Lewin's stage of refreezing?

The new mother attempts to breastfeed the baby again using the techniques recently acquired and is successful.

Which finding from a nursing audit reflects high standards for client safety and institutional health care?

The nurse documents clients' responses to nursing interventions.

A nurse is providing teaching to clients in a short-term rehabilitation facility. Which examples are common teaching mistakes made by health care professionals? Select all that apply.

The nurse ignores the restrictions of the client's environment. The nurse uses medical jargon frequently when discussing the teaching plan. The nurse fails to accept that clients have the right to change their minds

A nurse is writing learner objectives for a client who was recently diagnosed with type 2 diabetes. Which statement best describes the proper method for writing objectives?

The nurse writes one long-term objective for each diagnosis, followed by several specific objectives.

Arterial blood gasThe nurse is preparing to access an implanted port when administering intravenous fluids and medications. What best practice should be used when accessing this port?

The system is accessed with a noncoring needle and patency is maintained by periodic flushing.

n order to provide effective nursing care, the nurse should engage in what type of communication with the client and significant others?

Therapeutic communication

A nurse needs to select a venipuncture site to administer a prescribed amount of IV fluid to a client. The nurse looks for a large vein when using a needle with a large gauge. What explains the nurse's action?

To prevent compromising circulation

A nurse is presenting an in-service program to a group of graduate nurses about blood component therapy. The nurse determines that the education was successful when the group identifies which complication as the primary cause of transfusion-related client death in the United States?

Transfusion-related acute lung injury

Which of the following should be considered before planning change?

What is amenable to change How does the group function as a unit Is the group ready for change Are the changes minor or major

A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements?

a client who is homebound and needs skilled nursing care

A community health nurse is providing care to a group of Hispanic people living in an area that is heavily populated by white people. What are the Hispanic people in this community an example of?

a minority

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first?

a newly admitted 88-year-old with a 2-day history of vomiting and loose stools

How is control over the extracellular concentration of potassium within the human body is exerted?

aldosterone

A nurse communicating with a client states, "I will be changing your dressing, but we have plenty of time to talk first." She is already wearing sterile gloves and a mask and is busy working with her back to the client. The nurse is conveying:

an incongruent relationship

A home care nurse is teaching a client and family about the importance of a balanced diet. The nurse determines that the education was successful when the client identifies which of the following as a rich source of potassium

apricots

An evening shift nurse is caring for a client scheduled for a colon resection in the morning. The client tells the nurse she is afraid of waking up during surgery. The best response by the nurse is to:

ask the client why she thinks she will wake up during surgery.

A nurse manager informs the staff members during a meeting that unlicensed assistive personnel will no longer be allowed to check patients' blood glucose levels. The nurse manager informs the group this was a new policy on the unit, and discussions will not change the enforcement of this policy. What type of leadership style is the nurse manager demonstrating?

autocratic

On a medical unit, the nurses complain that they have no voice in the decisions that are made in the operation of the unit. The nurses state they are always told by the nurse manager to perform tasks instead of being asked. Which of these best describes the leadership style of the nurse manager?

autocratic

The parents of an infant suffering from apnea need to be educated on the apnea monitor and cardiopulmonary resuscitation. What should the nurse assess first regarding the parents?

baseline knowledge

A 20-year-old client reads the nutritional chart and follows it accurately. The nurse also notes that the client understands the need of a balanced diet and its relationship with a quick recovery. Which domain correctly identifies the client's learning style?

cognitive

The emergency department (ED) nurse is caring for a client who recently immigrated from China and was injured in a motor vehicle collision (MVC). The nurse should implement interventions aimed at addressing which issue?

cultural shock

A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status?

daily weights

A staff nurse works on a medical unit where staff retention is very high. There is a a sense of equality between the leader and the staff nurses. The unit decisions and activities are shared between the leader and the group. The designated nurse leader practices which of the following leadership styles?

democratic

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?

distended neck veins

source-oriented record

documentation system in which each health care group records data on its own separate form

PIE (problem, intervention, evaluation)

documentation system that does not develop a separate care plan; the care plan is incorporated into the progress notes in which problems are identified by number(in order they are identified), worked up using the problem (P)-intervention (I)-evaluation (E) format, and evaluated each shift

The nurse is monitoring intake and output (I&O;) for a client who recently had surgery. Which client actions will the nurse document on the I&O;record? (Select all that apply.)

drinking milk urination vomiting infusion of intravenous solution

The nurse is caring for a client who has been admitted for a new diagnosis of hypertension. When does the nurse begin client teaching?

during the admission process

When a client states, "I only want a white doctor," the client is expressing cultural:

ethnocentrism.

Which documentation tool will the nurse use to record the client's vital signs every 4 hours?

flow sheet

A nurse is assessing a client and determines that the client belongs to a minority group. Based on the nurse's understanding about minority groups, the nurse would anticipate that the client would likely experience which effects? Select all that apply.

health disparities less power

respiratory alkalosis

high pH, low CO2, hyperventilation

A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of:

hypokalemia

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes

limiting abbreviations to those approved for use by the institution.

respiratory acidosis

low pH, high CO2, hypoventilation

A nurse is caring for a client with pneumonia. Which task is most appropriate for the nurse to delegate to an experienced unlicensed assistive personnel (UAP)?

obtaining vital signs every 4 hours

The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy does the nurse identify as out of scope nursing practice?

ordering type of solution, additive, amount of infusion, and duration

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms indicative of:

phlebitis

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?

placing the tourniquet on the upper arm for 2 minutes

Role of Nurse Manager

planning, organizing, directing, controlling

A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client?

platelets

Mrs. Shields is a 46-year-old obese woman diagnosed with hypertension and type 2 diabetes. She tells the nurse that she knows she needs to lose weight. She recently visited her local fitness club, obtained a membership and has signed up for their next water aerobics class. According to the Transtheoretical Model of Change, what stage of change is Mrs. Shields in related to her weight loss?

preparation

Which of the following nursing models results in greater continuity of care?

primary nursing

A black client refuses to allow any health care worker of Asian descent to provide care. This client is demonstrating what practice?

racism

To improve communication within the health care system, tools were created to standardize the process and assist with clarity and conciseness. SBAR is one such tool. In this tool, what does R stand for?

recommendations

client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action?

remove iv

Arterial blood gases reveal that a client's pH is 7.20. What physiologic process will contribute to a restoration of correct acid-base balance?

renal retention of H ions

A decrease in arterial blood pressure will result in the release of:

renin

A client has a physician's order for n.p.o (nothing by mouth) following abdominal surgery to repair a bowel obstruction. The client has a nasogastric tube inserted to low intermittent suction. The client requires intravenous therapy for what purpose?

replace fluid and electrolytes

A nurse is working with a culturally diverse group of clients. The nurse understands that cultural norms:

require an individualized approach by the nurse.

The primary extracellular electrolytes are:

sodium, chloride, and bicarbonate.

A preconceived and untested belief about an individual or group of individuals is:

stereotyping

A student has joined the marching band at his high school. The band begins practicing outside in August. This student and other band members need to be instructed that:

the band members should drink large amounts of water.

Which client admitted to the emergency department (ED) might require the nurse to include interventions aimed at addressing cultural shock in the plan of care?

the client who recently immigrated from Mexico who fell from a ladder

Which client will have more adipose tissue and less fluid

woman

When teaching a group of unlicensed assistive personnel (UAP) about race, which statement by a UAP requires intervention by the nurse?

"People with common physical features share the same culture."

A 56-year-old executive meets with the nurse for education about recently diagnosed atrial fibrillation. He verbalizes concerns about the time he will spend away from his work, and that he is not sure it is necessary to have blood tests every week. He feels it is a waste of time when he does not have any symptoms. Which is the best motivational statement by the nurse for this client?

"The medicine and blood work for atrial fibrillation can help prevent blood clots that have the potential to cause debilitating strokes. What have you heard about warfarin therapy?"

A Hispanic client has been hospitalized for 6 days for postoperative infection. The client's weight is decreasing each day, and the nutritional intake is declining. Which nutritional assessment question is most appropriate?

"What type of food do you eat at home?"

A nurse is assessing vital signs on a pregnant client during a routine prenatal visit. The client states, "I know labor will be so painful, it sounds awful. I am sure I will not be able to stand the pain; I really dread going into labor." What is the best response from the nurse?

"You're worried about how you will tolerate the pain associated with labor."

Which statement by the nurse could effectively assist the nurse to implement a teaching session for cult clients?

- does anyone have any barriers. That would make it difficult to see or hear - this will be a short presentation and then i will use the last 15 injures for questions and answers - we will have our presentation in this room since its quieter with less distractions - session will only last 30 minutes

Which behaviors demonstrated by the client would the nurse consider as reflection of the client's pride in ethnicity? Select all that apply.

- requesting native cuisine - listening to folk music and dance - asking to wear person unique clothing

The nurse is preparing to teach four clients. Which client will the nurse plan to teach using principles associated with gerogogy?

79-year old who has slight cognitive changes

Which statement made by the nurse could effectively assist the nurse to implement a teaching session for adult clients? (Select all that apply.)

"Does anyone have any barriers that would make it difficult to see or hear the audiovisuals?" "This will be a short presentation and then I I will use the last 15 minutes for questions and answers." "We will have our presentation in this room since it is quieter with less distractions." "This session will only last for 30 minutes."

A nursing student is providing care to a postoperative client of Asian descent. The student reports to the primary nurse that the client is "eating food from home." What is the nurse's best response?

"Food from home is fine as long as it does not violate hospital policy or contradict the prescribed diet."

The nurse is talking with a client who is thinking about obtaining a second opinion regarding the surgeon's recommendation for surgery. Which response by the nurse is considered an advocacy response?

"Let us know if we can answer any further questions after you obtain your second opinion."

A nurse is demonstrating ethnocentrism. Which statement would reflect this concept?

"My Russian heritage is superior to all others."

A nurse is calling a physician to communicate a change in the client's condition. According to the ISBARR format for handoff communication among health care personnel, which is the most appropriate way to begin the conversation

"My name is Sue Smith, RN and I am calling regarding Mrs. Jones in room 356 at Jefferson hospital."

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response?

"Only authorized persons are allowed to access client records."

A nurse is counseling several clients for depression. Four of them do not seem to be improving, which leads the nurse to suggest a referral to a psychiatric nurse practitioner. Which of these clients would be most likely to attend the scheduled appointment?

A 28-year-old female; works nights, willing to try, asking about insurance coverage of appointment.

Which statement best describes the client most motivated to learn?

A 70-year-old female; learning care so spouse can come home

A nurse caring for clients of different cultures in a hospital setting attempts to make eye contact with clients when performing the initial assessment. What assumption might the nurse make based on common cultural practices?

A Muslim-Arab woman refuses to make eye contact with her male nurse. Assumption: She is being modest.

A nurse manager and the charge nurse have two employees who disagree with the accomplishment of client care. The manager determines a mutually agreed-upon time to discuss this situation with all the members involved. This activity is called what?

Conflict resolution

A family from China has recently immigrated. All members are quickly learning the language and the children are all in public school. Both parents are working and adapting to the new culture. What is this family demonstrating?

Cultural assimilation

The nurse is preparing to administer prescribed medication to a client who is Native American/First Nations. The nurse enters the room and observes a shaman performing a healing ritual for the client. What action would be the most appropriate by the nurse?

Leave the room and return when the shaman is finished.

A nurse evaluates whether a middle-age client with chronic back pain has been performing the different exercises and physiotherapy procedures recommended by the physician. What would the nurse most likely use to evaluate the client

Return demonstration

The nursing is caring for a client who requests to see a copy of his health care records. What action by the nurse is most appropriate?

Review the hospital's process for allowing clients to view their health care records.

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nurse implementing?

SOAP charting

A new client comes to the primary care clinic and asks for help treating head lice. The nurse assesses that the client lives in low-income housing, and nine other people live with the client in a one-bedroom apartment. Which consideration is the priority nursing concern?

The client does not have running water

The nurse is educating a client regarding a new skill. When evaluating the client's knowledge about the topic covered, what best represents that the client has learned a new skill?

The client organizes materials needed and gives return demonstration.

The nurse is writing learner outcomes for a client admitted with heart failure. Which learner outcomes statement is correctly written

The client will describe symptoms of hypokalemia associated with diuretic use.

The nurse is caring for a Hispanic client admitted with an upper respiratory infection. The client tells the nurse that they follow the holistic belief of hot/cold. Which food items should the nurse provide to the client based on this information?

soup, hot tea, and toast

Which of the nurse's actions is most likely to promote a client's compliance with their antiretroviral drug regimen for the treatment of human immunodeficiency virus (HIV)?

Use interactive and learner-appropriate teaching techniques

A client shares with the nurse how much she appreciates understanding the physiology of her breastfeeding. She states, "I felt very comfortable with what you explained to me and I feel I will be successful at breastfeeding." In affective learning, this represents:

creating an atmosphere for discussion of feelings.

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients:

have the right to copy their health records.

When a client says, "I don't care if I get better; I have nothing to live for, anyway," which type of counseling would be appropriate?

motivational

Which nursing action is applicable to the psychomotor domain of learning when conducting a teaching session for breastfeeding mothers?

observing a mother expressing the breast milk

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation?

omitting client's response to nursing interventions