Exam 3 Review Questions

The nurse is beginning a complete bed bath for a client. After removing the patient's gown and placing a bath blanket over her, which of the following areas should the nurse wash first? a. Eyes b. Hands c. Chest d. Legs

a. Eyes

The nurse is caring for a client who states that they have recently become a single parent. Which question by the nurse is appropriate to assess how this family structure change has affected the client? a. "Are tasks more difficult now that you don't have help?" b. "When did you and your partner separate?" c. "How many children live with you currently?" d. "Where did your partner go after you separated?"

a. "Are tasks more difficult now that you don't have help?"

The nurse is completing a health history for a middle-aged client. The client states, "I just got divorced last month." Which statement by the nurse would be most appropriate? a. "How has the divorce impacted your health?" b. "You will meet the right person when you are ready." c. "A lot of people get divorced." d. "Was that your first marriage?"

a. "How has the divorce impacted your health?"

A nurse is educating a client on insulin administration. Which statement made by the client indicates further teaching is required? a. "I will inject the insulin in the same site every day." b. "The best injection area is around my abdomen." c. "I will squeeze my skin together to inject the medication." d. "Gentle pressure should be applied to the site after injection."

a. "I will inject the insulin in the same site every day."

The nurse is caring for a client who is prescribed a new medication. Prior to the administration of the medication, which action by the nurse best demonstrates an awareness of safe and competent nursing practice? a. Ask the client for their name, date of birth and allergy history, then check the client's identification band. b. Verify the order for the medication on the admission sheet, then ask the client their name. c. Ask the client for their medical record number, then check the client's identification band. d. Verify the client's name on the admission sheet, then check the client's identification band.

a. Ask the client for their name, date of birth and allergy history, then check the client's identification band.

A nurse is preparing to administer intravenous medication to a client. Which action by the nurse ensures the medication is administered to the correct client? a. Asks the client to state their name and date of birth b. Verifies the medication has a client label c. Checks the medication against the prescription and the MAR d. Ensures the client has an identification wristband

a. Asks the client to state their name and date of birth

The nurse administers medication to the wrong client. Which action(s) should the nurse take when the medication error is identified? Select all that apply. a. Complete an incident report b. Force the client to vomit c. Report the error to the board of nursing d. Document the error in the medical record e. Notify the health care provider f. Monitor the client for adverse effects

a. Complete an incident report d. Document the error in the medical record e. Notify the health care provider f. Monitor the client for adverse effects

The graduate nurse is researching how to implement culturally congruent care into practice. Which action should the graduate nurse take first? a. Explore personal beliefs and values b. Read current literature on healthcare disparities c. Attend a conference on culture and nursing d. Interview nurses from different cultures

a. Explore personal beliefs and values

A self-sufficient bedridden patient is unable to reach all body parts. Which type of bath will the nurse assign to the nursing assistive personnel? a. Partial bed bath b. Bag bath c. Complete bed bath d. Shower

a. Partial bed bath

The nurse is admitting a client who does not speak English. Which of the following interventions should the nurse include when caring for the client? Select all that apply. a. Plan on taking twice as long as usual to complete nursing interventions. b. Pay attention to any effort by the client to communicate. c. Use a trained medical interpreter provided through the facility's interpreter service d. Make a note of the client's preferred language in their medical record. e. Verify that the client's 9-year-old child speaks English well before asking the child to translate. f. Speak in a loud voice and use exaggerated hand gestures to communicate with the client.

a. Plan on taking twice as long as usual to complete nursing interventions. b. Pay attention to any effort by the client to communicate. c. Use a trained medical interpreter provided through the facility's interpreter service d. Make a note of the client's preferred language in their medical record.

A nurse has asked a second nurse to sign for a wasted narcotic. The waste was not witnessed by the second nurse. What is the appropriate initial action? a. Report the situation immediately to the nurse manager or nursing supervisor b. Counsel the colleague about this risky behavior c. Confront the nurse about suspected drug use d. Sign the narcotic sheet then document the event in an incident report

a. Report the situation immediately to the nurse manager or nursing supervisor

A nurse has removed a 2 ml vial of fentanyl from the medication dispensing system. After dosage calculations, the nurse determines only 1 ml will be administered to the client. Which action will the nurse perform with the remainder of the medication? a. Request another nurse to witness wasting of the unused medication b. Dispose of the unused medication in the sink c. Store the unused of the medication in the medication cart d. Return the unused medication to the dispensing system

a. Request another nurse to witness wasting of the unused medication

The nurse is administering medication to a client through a percutaneous endoscopic gastrostomy (PEG) tube. Which action by the nurse will maintain the patency of the tube? a. Crush medication to a fine powder before pouring into the tube b. Flush the tube with water between each medication c. Push medication through the tube with water d. Keep the tube unclamped for an hour

b. Flush the tube with water between each medication

A nurse receives a prescription to administer 200 mcg of hydromorphone to a client. The hydromorphone is supplied in a 1 mg/ml vial. How many milliliters will the nurse administer to the client? a. 0.5 mL b. 0.2 mL c. 2 mL d. 2.5 mL

b. 0.2 mL

The nurse is preparing to administer a tuberculin test to an adult client. At what angle should the nurse administer the injection? a. 45-degree angle b. 15-degree angle c. 90-degree angle d. 20-degree angle

b. 15-degree angle

The nurse is caring for a Muslim client who practices prayer 5 times per day. Which of the following interventions should the nurse perform? a. Inform the client that he will not be able to perform prayer while the nurse is administering medications b. Ask the client for the prayer schedule to ensure that he has privacy during those prayer times c. Ask the charge nurse for a different client who does not practice any religion d. Allow the client to leave the hospital campus to perform his ritual

b. Ask the client for the prayer schedule to ensure that he has privacy during those prayer times

The nurse is preparing to administer medications to her assigned clients. To reduce medication errors, which of the following rights of medication administration should the nurse adhere to? Select all that apply. a. Place each client's medication on their bedside table during the beginning of shift rounds b. Check the medication against the medication administration record (MAR) c. Confirm the client's room number against the medication administration record (MAR) d. Maintain a distraction-free environment while administering medication e. Prepare injectable medications at the beginning of the shift before the shift becomes busy f. Verify the client's full name and date of birth in the medication administration record (MAR) g. Ensure the medication is in the right form as ordered by the health care provider (HCP)

b. Check the medication against the medication administration record (MAR) d. Maintain a distraction-free environment while administering medication f. Verify the client's full name and date of birth in the medication administration record (MAR) g. Ensure the medication is in the right form as ordered by the health care provider (HCP)

The nurse is caring for a 28-year-old female who was recently diagnosed with cancer and had to quit her job due to the physical complications of the disease. The client states "I am so depressed that my husband now has to take care of the kids and me while still working full time. I feel guilty that I no longer financially contribute to our household". Which of the following is the client struggling with? a. Body Image b. Role performance c. Identity d. Sexuality

b. Role performance

A client is asking the nurse about shaving his face today. Which of the following should the nurse do? Select all that apply. a. Inform the client that he will have to shave on his own b. Shave in the direction of hair growth c. Check if the client is on bleeding precautions d. Ask the client if he would prefer soap or shaving cream e. Inform the client that shaving is not allowed on the unit

b. Shave in the direction of hair growth c. Check if the client is on bleeding precautions d. Ask the client if he would prefer soap or shaving cream

The emergency department (ED) nurse is caring for assigned clients. The culturally competent nurse is aware that which client is at the greatest risk for cultural disparity? a. The client who is Caucasian who is reporting chest pain b. The client who recently immigrated from Mexico who fell from a ladder c. The client who is an African American who has a history of COPD d. The client who is a Native American who was admitted with flu-like symptoms

b. The client who recently immigrated from Mexico who fell from a ladder

The nurse is interviewing a client about home medications. Which of the following information should the nurse document in the medical record as a part of the medication reconciliation? a. The client's demographic information b. The frequency of each medication c. The client's preferred pharmacy d. The name of the provider that prescribed each medication

b. The frequency of each medication

All nurses should work to provide culturally appropriate nursing care. What is the integration of cultural knowledge into all aspects of care? a. Cultural competence b. Transcultural nursing c. Nursing process d. Cultural Desire

b. Transcultural nursing

The nurse is preparing to administer an intramuscular injection to an adult client using the deltoid site. Which of the following needle sizes would be an appropriate choice for this injection? a. 18 gauge, 5/8 inch needle b. 30 gauge, 2 inch needle c. 23 gauge, 1 inch needle d. 16 gauge, 1.5 inch needle

c. 23 gauge, 1 inch needle

The nurse is performing an admission assessment on a client who only speaks Spanish. What is the most appropriate action for the nurse? a. Ask the client's daughter about the client's chief concerns and medical history b. Ask one of the Hispanic nurses to come interpret c. Call for a Spanish interpreter and wait to conduct the assessment d. Inform the charge nurse about the inability to document a full assessment due to the language barrier

c. Call for a Spanish interpreter and wait to conduct the assessment

The nurse is caring for a 20-year-old admitted for uncontrolled diabetes and hyperglycemia. According to Erikson, which of the following stages is the adult in? a. Integrity vs. Despair b. Identity vs. Role confusion c. Intimacy vs. Isolation d. Generativity vs. Stagnation

c. Intimacy vs. Isolation

The nurse is preparing to administer a medication via a transdermal patch to a client. Which action by the nurse is appropriate? a. Apply lotion to the skin prior to placement b. Utilize heat therapy over top of the patch after placement c. Remove the previous patch prior to placement d. Apply the patch in the same location as the previous placement

c. Remove the previous patch prior to placement

The nurse is preparing to administer a subcutaneous injection to a client. Which of the following locations would be an appropriate administration site? a. Dorsal surface of the hand b. Ventral gluteal site c. Right upper quadrant of the abdomen d. Deltoid of the right arm

c. Right upper quadrant of the abdomen

The female nurse is caring for a male patient who is uncircumcised but not ambulatory and has full function of all extremities. The nurse is providing the patient with a partial bed bath. How should perineal care be performed for this patient? a. Should be unnecessary because the patient is uncircumcised. b. Should be done by the nurse. c. Should be done by the patient. d. Should be postponed because it may cause embarrassment.

c. Should be done by the patient.

The nurse is reviewing a client's MAR and sees a new medication order for acetaminophen 650 mg BID. The nurse will administer the medication when?

c. Twice a day

The nurse is caring for a client who is 4 days post-op following a below-the-knee amputation. Which of the following statements indicates the client has a distorted body image? a. "I'll be able to function like I did before the operation" b. "I just cannot stop crying" c. "I'm so angry that this happened to me" d. "I cannot look at my leg. Just hurry and change the dressing"

d. "I cannot look at my leg. Just hurry and change the dressing"

The visiting nurse is caring for a 55-year-old female client who had a right radical mastectomy several months ago. Which client statement is most indicative of the possibility that the client is not coping well with an altered body image? a. "I guess it's time for me to quit wearing a bikini at my age anyway." b. "It really isn't much of a problem for me, I never had large breasts anyway." c. "I plan to volunteer to work with others who have had a mastectomy." d. "I only look at myself in the mirror after I am fully dressed."

d. "I only look at myself in the mirror after I am fully dressed."

Which of the following clients would be at the expected Integrity vs. Despair stage of psychosocial development? a. 2-year-old b. 15-year-old c. 30-yearold d. 81-year-old

d. 81-year-old

A client of South American heritage refuses emergency treatment until a curandero is called. A curandero is a type of folk healer. What should the nurse understand about the client's request? a. The nurse must first obtain approval from the client's health care provider. b. The client's superstitious beliefs will interfere with appropriate treatment. c. The use of holistic healing practices will eliminate the need for medical treatment. d. Culturally competent care should incorporate the client's preferences.

d. Culturally competent care should incorporate the client's preferences.

The nurse is preparing to administer an enoxaparin injection to a client who is immobilized after a cerebrovascular accident. The client voices concern and refuses to take the medication. What actions should the nurse take? Select all that apply. a. Ask the client's significant other for permission to give the medication b. Notify the pharmacist to discontinue the medication c. Ask the client if they prefer the medication in an oral form d. Ensure the client correctly understands the medication's purpose e. Confirm the client understands the risks associated with not taking the medication f. Clarify the reason why the client is refusing the medication

d. Ensure the client correctly understands the medication's purpose e. Confirm the client understands the risks associated with not taking the medication f. Clarify the reason why the client is refusing the medication

The nurse is preparing to administer prescribed medication to a client. The nurse notes the packaging for the medication is provided in a different route than prescribed. Which action should the nurse take? a. Administer the medication as ordered b. Consult the pharmacist regarding the error c. Alert the charge nurse to the medication error d. Contact the health care provider

b. Consult the pharmacist regarding the error

The nurse is caring for a client who is terminally ill and recently immigrated to the United States. The nurse understands that to provide quality end-of-life care for the client, which action by the nurse should be a priority? a. Make every effort to involve the client and the client's family with end-of-life care b. Understand the client's personal and cultural views regarding death and dying c. Arrange for end-of-life care to be provided by staff familiar with the client's culture d. Share the client's concerns regarding the dying process with the interdisciplinary care team

b. Understand the client's personal and cultural views regarding death and dying

The nurse is teaching a female client about proper perineal hygiene care. Which of the following comments by the client indicates understanding? a. "I will wash my peri area after cleaning my buttocks". b. "I will wash my peri area with soap twice a day" c. "I will wash my peri area from front to back" d. "I will use one wash cloth to clean my legs and peri area"

c. "I will wash my peri area from front to back"

After the death of a client, the family approaches the nurse and requests that a family member be allowed to perform a ritual bath on the deceased client prior to moving the body. What would be the most appropriate response by the nurse? a. "A ritual bath will have to wait until after postmortem care." b. "I will have to check on hospital regulations and policies." c. "Is there anything you need from me to perform the bath?" d. "These procedures have to be carried out by our staff."

c. "Is there anything you need from me to perform the bath?"

The nurse is conducting medication administration with the client. When given an intravenous (IV) medication, the client says to the nurse, "I usually take pills. Why does this medication have to be given in my arm?" Which nursing response is appropriate? a. "The medication will cause fewer adverse effects if given intravenously." b. "The intravenous medication will be absorbed into the bodies' tissues more slowly." c. "The medication will begin to work sooner when given intravenously." d. "There is a lower chance of allergic reaction when medications are given intravenously."

c. "The medication will begin to work sooner when given intravenously."

The nurse is planning to administer otic drops to an adult client. Which action is part of the correct procedure? a. Insert cotton in the inner ear after giving medication b. Place several drops in the outer ear c. Assist the client to lie on the affected side afterward d. Hold the pinna up and back to instill the drops

d. Hold the pinna up and back to instill the drops

The nurse is preparing to administer eye drops to a 6-year-old child. Which of the following is the correct method the nurse should use when instilling eye drops to the client? a. In the corner where the lids meet b. On the anterior surface of the eyeball c. Under the upper lid as it is pulled upward d. In the conjunctival sac as the lower lid is pulled down

d. In the conjunctival sac as the lower lid is pulled down

A nurse is preparing a medication for a client in the medication room. The nurse receives an emergency call while withdrawing medication into a syringe. Which action should the nurse take? a. Discard the medication from the syringe into the sink b. Place the syringe in the clothes pocket before leaving the medication room c. Leave the syringe on the counter in the medication room d. Store the syringe in the client's drawer in the medication cart

d. Store the syringe in the client's drawer in the medication cart