FUNDA 1: basic care & comfort/pain mgt 75; GI/nutrition 2; neuro 1
A client has been hospitalized with bipolar disorder, manic episode. The nursing care plan includes the diagnosis "Imbalanced nutrition: less than body requirements." Which of the following meal selections would be best for the client? 1. Banana smoothie, hamburger, French fries 2. Carrot sticks, turkey wrap sandwich, lemonade 3. Chicken and rice, fresh orange slices, iced tea 4. Meat loaf with gravy, mashed potatoes, apple pie, milk
1
A client who lives alone had a total laryngectomy for laryngeal cancer 3 months ago. The client has a tracheoesophageal puncture (TEP) to enable speech and tells the nurse, "It's a good thing it's cold outside, so I can keep the hole in my neck covered up with a scarf. I don't know what I'll do when the weather gets warmer." What is the most appropriate nursing diagnosis? 1. Disturbed body image 2. Impaired verbal communication 3. Ineffective coping 4. Ineffective self-health maintenance
1
An adolescent client is brought to the emergency department after being in a serious motor vehicle crash. The client is undergoing cardiopulmonary resuscitation. The nurse calls the family to inform them to come to the hospital and a family member asks how the client is doing. Which is an example of the ethical principle of beneficence when responding to the client's family? 1. "He is critically ill and we are caring for his needs." 2. "His heart has stopped and we are attempting to revive him." 3. "I don't know how he is doing but you need to come." 4. "I will have the health care provider talk to you once you arrive."
1
The health care provider prescribes intravenous fluid resuscitation for a client in hypovolemic shock. The nurse should anticipate the rapid infusion of which intravenous solution initially? 1. 0.9% Sodium chloride 2. 5% Albumin 3. Dextrose 5% and lactated Ringer's 4. Dextrose 5% and water
1
The nurse is teaching a client of American Indian heritage how to self-administer insulin. As the nurse describes the necessary steps in the injection process, the client continuously avoids eye contact and occasionally turns away from the nurse. Which action is most appropriate for the nurse to take in this situation? 1. Continue teaching the client and verify understanding by return demonstration 2. Discuss how important it is for the client to pay attention during the teaching 3. Maintain eye contact during the teaching by following the client's movements 4. Provide written instructions and a private place for the client to learn independently
1
The unit implemented a quality improvement program to address client pain relief. Which set of criteria is the best determinant that the goal has been met? 1. Chart audits found clients' self-reported pain scores improved by 10% 2. Number of narcotics used on the unit increased by 20% 3. Positive comments on returned client satisfaction surveys increased by 30% 4. Survey found that 90% of the nurses believed clients had better pain control
1
A postoperative client with obesity and diabetes mellitus has an abdominal wound and is at risk for poor wound healing. Which interventions would the nurse include in the plan of care to prevent wound dehiscence? Select all that apply. 1. Administer docusate orally, daily 2. Administer ondansetron IV PRN for nausea 3. Apply an abdominal binder 4. Implement caloric restriction to promote weight loss 5. Monitor blood sugar to maintain tight glucose control
1,2,3,5
The inpatient hospice nurse is caring for a Muslim client newly admitted with terminal cancer. Which of the following interventions would the nurse anticipate for this client? Select all that apply. 1. Arrange for health care workers of the same sex to provide care for the client 2. Coordinate with the registered dietician to provide halal meals 3. Reposition the immobile client to face the city of Mecca during daily prayer times 4. Restrict the number of visitors from the family to preserve the client's privacy 5. Upon death, provide the family with supplies for postmortem care
1,2,3,5
Which emergency department clients cannot be allowed to sign out against medical advice (AMA)? Select all that apply. 1. Client who drank 1 bottle of vodka 2 hours ago 2. Client who hears voice commands to kill the employer 3. Client with ST elevation on electrocardiogram tracing 4. A pregnant 14-year-old client with vaginal spotting 5. Client who insists on being the embodiment of Jesus Christ
1,2,5
The nurse is providing postmortem care for a client who just died after a long illness and hospitalization. The client had a do-not-resuscitate order in place at the time of death. A family member was at the bedside when the client died. What interventions should the nurse include during postmortem care? Select all that apply. 1. Allow family member to assist with care 2. Call the medical examiner for an autopsy 3. Place a pad under the perineum 4. Remove lines and tubes from the body 5. Remove the client's dentures
1,3,4
A client admitted 3 days ago with upper gastrointestinal bleeding underwent an endoscopic procedure to stop the bleeding. The client is started on a clear liquid diet today. Which foods are appropriate for the nurse to offer the client? Select all that apply. 1. Apple juice 2. Cherry popsicle 3. Chicken bouillon 4. Frozen yogurt 5. Unsweetened tea 6. Vanilla ice cream
1,3,5
A nurse is caring for a client who is meeting with the palliative care team. After the meeting, the client's family asks for clarification about palliative care. Which statements about palliative care are accurate? Select all that apply. 1. Palliative care focuses on quality of life and can be provided at any time 2. Palliative care is only possible with a terminal diagnosis of ≤6 months 3. Palliative care is provided by a multidisciplinary team 4. Palliative care is another term for hospice care 5. Palliative care provides relief from symptoms associated with chronic illnesses
1,3,5
The clinic nurse educator is developing a teaching plan for the following 6 clients. The nurse should instruct which client to avoid the Valsalva maneuver when defecating? Select all that apply. 1. 22-year-old man with a head injury sustained during a college football game 2. 30-year-old woman recently hospitalized for reconstructive augmentation mammoplasty 3. 56-year-old man 2 weeks post myocardial infarction 4. 68-year-old woman recently diagnosed with pancreatic cancer 5. 74-year-old man with portal hypertension related to alcohol-induced cirrhosis 6. 82-year-old woman 1 week post cataract surgery
1,3,5,6
A client is brought to the emergency department with multiple trauma injuries. The nurse sees the client's Jehovah's Witness identification card. As part of providing culturally competent care, the nurse would anticipate the client accepting which of the following? Select all that apply. 1. Epoetin alfa 2. Fresh frozen plasma 3. Homologous packed red blood cells 4. Normal saline 5. Platelet transfusion
1,4
A client is taking morphine sulfate for acute pain. The client stands, is immediately "lightheaded," and calls for the nurse. What is the nurse's priority action? 1. Assess the client's orthostatic blood pressure 2. Assist the client to a sitting position 3. Hold and walk with the client 4. Keep the client on bed rest
2
A client on hospice home care is taking sips of water but refusing food. Family members appear distressed and insist that the personal care worker "force feed" the client. What is the priority nursing action? 1. Explain to the family that this is a normal physiological response to dying 2. Explore the family's thoughts and concerns about the client's refusal of food 3. Recommend a feeding tube 4. Tell the family that "force feeding" the client could cause the client to choke on the food
2
A client with renal failure recently started dialysis and is unable to work due to ongoing health problems. The client's spouse has started working for a cleaning service to replace the lost income. The dialysis nurse notices that the client has become withdrawn and increasingly frustrated by small inconveniences when coming to dialysis. Which is the most appropriate first response by the nurse? 1. "How is your spouse's new job going?" 2. "I notice that you seem frustrated." 3. "It can take time to adjust to dialysis. We have a support group that can be helpful." 4. "It's normal to be angry when you can't work any longer."
2
A student nurse asks why enteral (tube) feedings, rather than total parenteral nutrition (TPN), are being administered to a client with sepsis and respiratory failure. Which is the best response by the registered nurse? 1. "Enteral feedings have no complications." 2. "Enteral feedings maintain gut integrity and help prevent stress ulcers." 3. "Enteral feedings provide higher calorie content." 4. "Risk of hyperglycemia is lower with enteral feedings than with TPN."
2
A teenage client with sickle cell disease is admitted with a diagnosis of crisis. The client's current prescription is morphine 2 mg intravenous push every 4 hours prn. The client appears comfortable while watching television and tells the nurse "I have severe intolerable pain," and rates it a "10." What action should the nurse take? 1. Call the client's health care provider (HCP) to obtain a ibuprofen prescription for pain relief 2. Call the HCP for patient-control analgesia (PCA) at a higher dose of the same drug 3. Contact the HCP who issued the prescription to switch to meperidine 4. Realize the client is exhibiting signs of addictive behavior and needs an appropriate consult
2
Based on the nursing assessment progress notes, what is the correct staging of the client's pressure ulcer? Click on the exhibit button for additional information. EXHIBIT: Progress notes 1300 Shallow, open area with dark pink wound bed about 1 cm in diameter noted on coccyx. Surrounding area is slightly hard and warm to touch with erythema. Enterostomal consult made. ________________, RN 1. Stage I 2. Stage II 3. Stage III 4. Stage IV
2
During a home visit, the community health nurse observes bruises in various stages of healing on the extremities and torso of an elderly client. The client explains that the bruises are from bumping into furniture and the wall in the wheelchair. What is the priority nursing action? 1. Ask the client to explain the bruises on the torso 2. Assess the client's general hygiene and nutritional status 3. Report the bruises to the client's health care provider (HCP) 4. Talk to the client's child about the injuries
2
In which position would the nurse place a client recovering from a right modified radical mastectomy who is admitted from the post-anesthesia unit? 1. High-Fowler's position with the affected side's arm resting on the bed 2. Semi-Fowler's position with the affected side's arm on several pillows 3. Supine with the affected side's arm on several pillows 4. Supine with the affected side's arm resting on the bed
2
The charge nurse in the telemetry unit has delegated the task of giving a bed bath to a male Arab client. Which communication to the female nursing assistant demonstrates appropriate cultural sensitivity? 1. "Do not make eye contact with the client during the bath." 2. "Make sure the client's wife is present during the bath." 3. "The client may prefer for you not to talk to him during the bath." 4. "Touching the head is a sign of disrespect, let the client wash his own face."
2
The emergency department nurse would administer a prescribed isotonic crystalloid solution to which client? 1. 25-year-old with a closed-head injury and signs of increasing intracranial pressure (ICP) 2. 45-year-old with acute gastroenteritis and dehydration 3. 68-year-old with chronic renal failure and hypertensive crisis 4. 60-year-old with seizures and serum sodium of 112 mEq/L
2
The family of a terminally ill, dying client verbalizes concern that the client is becoming dehydrated due to poor fluid intake. When the family asks the nurse about administering IV fluids, the nurse's response is based on an understanding of which statement? 1. Providing artificial hydration at the end of life will make the client feel more comfortable 2. The decision whether to provide artificial hydration should consider client preferences and goals 3. The health care provider will prescribe artificial hydration when the client can no longer swallow 4. Withholding artificial hydration at the end of life speeds up the dying process
2
The nurse learns that an Orthodox Jewish client has not started taking recently prescribed diltiazem extended-release capsules. The client states "I cannot take the medication in this form." What is the nurse's first action? 1. Ask the health care provider to prescribe a different calcium channel blocker 2. Consult with the pharmacist to see if an alternate form of the drug is available 3. Open the capsule and sprinkle the medication in a cup of applesauce 4. Warn the client about the dangers of uncontrolled hypertension
2
The nurse observes a client who is postoperative total right hip replacement use a cane. Which action by the client indicates an understanding of the correct technique when walking down the stairs? 1. Descends with the cane on the step first, followed by the left leg and then the right leg 2. Descends with the cane on the step first, followed by the right leg and then the left leg 3. Descends with the left leg on the step first, followed by the cane and then the right leg 4. Descends with the right leg on the step first, followed by the left leg and then the cane
2
The nurse practicing on a medical surgical unit assesses a group of clients. Which finding related to intravenous (IV) therapy requires the most immediate action by the nurse? 1. A client scheduled for discharge later that day has had an IV line in place for 72 hours 2. A client with a "do-not-resuscitate" prescription has an IV site that is red and swollen 3. A client with a saline lock has a scheduled IV saline flush due 4. A client with an IV line infusing at 20 mL/hr has 100 mL fluid remaining in the bag
2
Which client is at greatest risk for the development of hospital-acquired pressure ulcers (HAPUs)? 1. 25-year-old quadriplegic client with urosepsis, temperature of 101 F (38.3 C), and white blood cell (WBC) count of 18,000 µL 2. 50-year-old client with AIDS, weight loss of 20 lb (9 kg) in a month, prealbumin level <10 mg/dL, mean arterial blood pressure of 50 mm Hg, and receiving Levophed infusion 3. 80-year-old client 2 days postoperative from hip replacement, with dementia, two Jackson-Pratt drains, and hemoglobin level of 14 g/dL 4. 85-year-old client 2 days postoperative from open cholecystectomy
2
The nurse initiates prescribed intravenous (IV) therapy on an 86-year-old hospitalized client. Which life span concept(s) should be considered when initiating IV therapy and caring for an older adult receiving IV therapy? Select all that apply. 1. Avoid infusion devices in confused clients as alarms can be disruptive 2. Cardiac and renal changes may put the client at risk for hypervolemia 3. Older adults may have more fragile veins, increasing the risk of infiltration 4. Skin protectants and nonporous tape are helpful in reducing skin tears on fragile skin 5. Use a 30-45-degree angle on insertion because older adults have deeper veins that roll
2,3,4
A nurse is caring for a client with blindness due to diabetic retinopathy. Which interventions should the nurse implement for this client? Select all that apply. 1. Ask a family member about the client's preferences for room arrangement 2. Offer the client an elbow to hold, and walk a half-step ahead for guidance 3. Say "goodbye" when leaving the room to help orient the client 4. Speak slowly and slightly louder so the client can understand 5. Use a clock-face pattern to explain food arrangement on the client's meal tray
2,3,5
A young Spanish-speaking client is experiencing a spontaneous abortion (miscarriage). Which illustrates the best use of an interpreter to explain the situation to the client? Select all that apply. 1. Ask the client to nod so the nurse can confirm the client understands the situation 2. Attempt to use a female interpreter to avoid gender sensitivity 3. Make good eye contact with the client (rather than the interpreter) when speaking 4. Preferably use a personal friend or relative to facilitate client privacy under HIPAA 5. Teach about one intervention at a time and in the order it will occur
2,3,5
A client is being discharged after having a coronary artery bypass grafting (CABG) x 5. The client asks questions about the care of chest and leg incisions. Which instructions should the registered nurse include? Select all that apply. 1. Report any itching, tingling, or numbness around your incisions 2. Report any redness, swelling, warmth, or drainage from your incisions 3. Soak incisions in the tub once a week then clean with hydrogen peroxide and apply lotion 4. Wash incisions daily with soap and water in the shower and gently pat them dry 5. Wear an elastic compression hose on your legs and elevate them while sitting
2,4,5
The nurse is providing hospice care to a terminally ill client who is reporting dyspnea. Which interventions are appropriate at this time? Select all that apply. 1. Administer high-flow oxygen via facemask 2. Administer prescribed PRN morphine 3. Increase the client's activity level 4. Provide portable fan to blow cool air on the client's face 5. Provide relaxation strategies such as music and guided imagery
2,4,5
A client expresses concern about facial appearance after surgery for excision of a melanoma on the side of the nose. What is the best response by the nurse? 1. "Have you shared your concerns with your health care provider (HCP)?" 2. "If I were you, I would be more worried about whether the melanoma has spread." 3. "Scar tissue formation is part of the natural healing process. We will teach you how to care for your wound to minimize any complications." 4. "There is special make-up you can use to hide any facial scars left from the surgery."
3
A client recovering at home following a left total knee replacement 7 days ago is using a cane to go up and down the stairs under the supervision of the home health nurse. Which client action indicates a need for further instruction? 1. Faces forward when going up and down the stairs 2. Holds the cane with the right hand 3. Leads with left leg, follows next with cane, and finally right leg when going up the stairs 4. Places full weight on left leg when going down the stairs
3
A nurse is documenting notes in the client's electronic record after making rounds on assigned clients. Which entry is an appropriate documentation? 1. Client appears to be sleeping. Eyes closed. 2. Client reports, "I'm in pain." Medication provided. 3. Inspiratory wheezes heard in bilateral lower lung fields 4. Voided x 1
3
A registered nurse is precepting a new nurse in the intensive care unit. The client is sedated with propofol, on a mechanical ventilator, and is receiving enteral feeding via nasogastric tube. The new nurse performs interventions to prevent aspiration. The preceptor should intervene if the new nurse performs which of the following actions? 1. Assesses gastric residual volumes every 4 hours 2. Measures the number of centimeters the feeding tube is secured at the nare every 4 hours 3. Requests that the physician change the client from continual to bolus feedings 4. Uses a sedation scale to titrate down the sedation (if possible)
3
An Islamic woman is admitted through the emergency department after falling and sustaining a head injury. What is the priority nursing action? 1. Allow the client's husband to be with the client in the examining room 2. Assign the client to a private room 3. Ensure that only female health care workers provide care to the client 4. Obtain the services of a medical interpreter
3
The nurse enters a client's room and finds that the client and spouse are crying. The spouse states that the health care provider just diagnosed the client with Alzheimer disease. What is the best response by the nurse? 1. "Do you have any questions about the diagnosis?" 2. "There are medications available to treat Alzheimer disease." 3. "This new diagnosis must be frightening for you." 4. "We can help you make decisions about your care."
3
The nurse is caring for a 48-year-old executive on the cardiac unit who has just been diagnosed with primary hypertension. Which teaching strategy implemented by the nurse is most likely to be effective for this client? 1. Leave diet pamphlets for the client to review at a later time 2. Refer the client to the nurse case manager to follow up with diet instructions 3. Sit with the client during meal selections and assist with identification of low sodium options 4. Turn the television on in the client's room to the patient education channel to watch
3
The nurse is conducting a home visit to assess an elderly client with advanced heart failure who lives alone. When the nurse asks about sodium intake, the client becomes angry and says, "I'm so tired of people telling me what to do! I'm going to eat what I want, so leave me alone!" Which of the following is the most appropriate response by the nurse? 1. "I can tell that you want me to go, so I will call in a few days to see how you are doing." 2. "I know you are frustrated with losing control of your life." 3. "It sounds like you are angry. Tell me what's bothering you." 4. "Okay. I'll just check your blood pressure and then go."
3
A client is advanced to a full liquid diet on the third day after bariatric surgery. Which group of food selections would be the best choice for this client? 1. Apple juice, pudding, chicken broth 2. Cheese omelet, mashed potatoes, custard 3. Low-fat yogurt, sherbet, vegetable juice 4. Oatmeal, cream of chicken soup, protein shake
4
A client newly returned to the unit after knee surgery asks the nurse for assistance to a chair. What action should the nurse implement first? 1. Ask another nurse to help 2. Delegate the task to unlicensed assistive personnel 3. Premedicate the client for pain 4. Verify the client's activity prescription
4
A client of the Jewish Orthodox faith with a history of type 2 diabetes mellitus is hospitalized, recovering from a total right hip arthroplasty. At noon, the client consumed the following meal: lean roast beef sandwich with lettuce and low-fat mayonnaise, carrot and celery sticks, and fresh fruit. What would be the most appropriate 2:00 PM snack for this client? 1. Angel food cake with fresh strawberries 2. Crackers and low-fat cheese 3. Nonfat plain yogurt 4. Pita chips and hummus
4
A client with multiple co-morbidities, including chronic obstructive pulmonary disease, diabetes, and chronic kidney disease, has just been told by the health care provider of the need to start dialysis. The client is in tears and says to the nurse, "I don't know what I'm going to do; everything was so overwhelming before, and now this." Which is the best response by the nurse? 1. "But you need the dialysis to stay alive." 2. "I hope that a kidney donor will be found for you very soon." 3. "It won't be so bad; you might even feel better with dialysis." 4. "Tell me more about what has been overwhelming for you."
4
A legally blind client is being prepared to ambulate 1 day after an appendectomy. What is the most appropriate action by the nurse? 1. Arrange for the client's service dog to come to the health care facility as soon as possible 2. Describe the environment in detail so the client can ambulate safely with a cane 3. Instruct the unlicensed assistive personnel to walk beside the client and lead by the hand 4. Walk slightly ahead of the client with the client's hand resting on the nurse's elbow
4
An elderly client with end-stage renal disease who has refused dialysis is admitted to a long-term care facility for rehabilitation following hospitalization. The next day, the client becomes agitated and says to the nurse, "I've got to get back home to my things. I have so much to do." Which is the most likely interpretation of this client's behavior? 1. The client has been admitted to the facility without the client's consent 2. The client is becoming delirious and should be assessed for infection 3. The client is concerned that someone might steal possessions 4. The client wants to take care of business before imminent death
4
It is 0700 and the nurse is caring for an 84-year-old client with dementia and a fractured hip. The client has been disoriented to time, place, and person since admission. The client moans frequently and grimaces when moving. He is prescribed morphine IV every 2 hours as needed for pain and was last medicated at 0530. He is scheduled for surgery at 1000 to repair the hip fracture, but the consent has not yet been signed. The client's spouse and child are to arrive at 0900. Which intervention should the nurse carry out first? 1. Administer pain medication 2. Call the health care provider to meet with the family to obtain informed consent 3. Complete the preoperative checklist 4. Perform the morning assessment
4
The home health nurse is following up with the parent of a Native American infant recently diagnosed with lactose intolerance. In accordance with principles of culturally competent care, what is the most important question for the nurse to ask the parent? 1. Do your other children have this condition? 2. How long did your infant have diarrhea? 3. How often are you feeding the infant? 4. What do you think caused your infant's illness?
4
The nurse is caring for a client with end-stage liver disease who was admitted for bleeding esophageal varices. The bleeding varices were banded successfully, but the client declined having a transjugular intrahepatic portal-systemic shunt (TIPS) procedure and opted for do not resuscitate (DNR) status. Which topic is most important for the nurse to discuss with the client and family at discharge? 1. Complete abstinence from alcohol 2. Proper use of medications including lactulose 3. The importance of calling the healthcare provider (HCP) immediately if bleeding recurs 4. The purpose and use of the DNR bracelet
4
The nurse is caring for an elderly client after hip replacement surgery. The client is distressed because he has not had a bowel movement in 3 days. Which action by the nurse would be most appropriate? 1. Administer the prescribed as-needed milk of magnesia 2. Ask dietary services to add more fruits and vegetables to the client's tray 3. Notify the health care provider (HCP) 4. Perform a focused abdominal assessment
4
The client has a dislocated shoulder and the nurse is assisting the health care provider with bedside procedural moderate sedation (conscious sedation). During the procedure, the client becomes restless and cries out "Help me!" What action should the nurse take first? 1. Administer midazolam per protocol 2. Check the client's pulse oximeter 3. Give more morphine per protocol 4. Open the airway with head tilt-chin lift
2
For the past month, the registered nurse (RN) has been providing care to a 7-year-old client recently diagnosed with type 1 diabetes mellitus. Initially, the family seemed devastated over the diagnosis. The client's parent stated, "Our lives will never be the same." What statement now made by the parent best indicates that nursing interventions have been effective? 1. "Our child will not be able to participate in sporting events." 2. "Our whole family will have to make sacrifices to deal with this disease." 3. "We cannot let this disease control our child's life." 4. "We have set aside a place in the pantry for our child's special foods."
3
The nurse is performing an admission assessment on an elderly client with Alzheimer disease (AD). The nurse should do which of the following when communicating with the client? 1. Ask open-ended questions 2. Speak in a loud voice 3. Touch the client prior to speaking 4. Use simple sentences
4
A 55-year-old client on a medical-surgical unit has just received a diagnosis of pancreatic cancer. The client says to the nurse, "Is this disease going to kill me?" What is the best response by the nurse? 1. "Hearing this diagnosis must have been difficult for you. What are your thoughts?" 2. "We will do everything possible to prevent that from happening." 3. "Well, we're all going to die sometime." 4. "You should concentrate on getting better rather than thinking about death."
1
A client calls the nurse to report exacerbation of chronic lower back pain after working in the yard all weekend. Knowing that this worsened back pain is probably due to acute inflammation, the nurse recommends which nonpharmacologic intervention? 1. Heating pad 2. Positioning for comfort 3. Rest from pain-aggravating activities 4. Stretching exercises
3
The registered nurse (RN) is providing nursing care with a licensed practical nurse and unlicensed assistive personnel. The RN administers hydromorphone 1.5 mg IVP per STAT order to a client with severe abdominal pain. Three hours later, the client rates pain as a 9 on a scale of 0-10 and requests pain medication. What is the most appropriate action for the RN to take? 1. Administer the hydromorphone 2. Ask the licensed practical nurse to administer the medication 3. Ask the unlicensed assistive personnel to take repeat vital signs 4. Contact the health care provider
4
FUNDA basic care... 35 multiple choice with images http://author.udutu.com/myudutu/preview/previewcourse.aspx?CourseID=137491&ScreenID=4348600
c
The nurse is providing discharge instructions to a 70-year-old client newly diagnosed with heart failure who has a low literacy level. What are some teaching strategies that the nurse can use for this client? Select all that apply. 1. Conduct teaching sessions while a family member is present 2. Discourage the client from using the internet to look up health information 3. Have client watch a DVD about heart failure management 4. Print out pictures of a food label and review where to look for sodium content 5. Speak slowly and loudly so the client can understand you
1,3,4
The client screams at the nurse, "You are all incompetent here! I have been waiting for 2 hours!" How should the nurse respond initially? 1. "I know you are upset, but I will have to call security if you continue to scream." 2. "I see that you are upset. Let's focus on how I can help you." 3. "I want you to know that the health care providers (HCPs) are all well-qualified professionals." 4. "It is frustrating to wait so long, and I am sorry for the delay."
4
The nurse is teaching a client with insomnia techniques to improve sleep habits. Which statement by the client indicates a need for further teaching? 1. "I will avoid caffeine with dinner." 2. "I will avoid naps later in the day." 3. "I will keep my bedroom cool." 4. "I will read in bed if I can't fall asleep."
4
Funda basic care #75 - Drag and drop http://author.udutu.com/myudutu/preview/previewcourse.aspx?CourseID=137491&ScreenID=4348599
c
A client has just returned to the room after having a mammogram. The client is teary and in a shaky voice says to the nurse, "The radiology technician told me that it looks really bad - the tumor in my breast is very large." Which is the best response by the nurse? 1. "I can see that you are very upset. Let's talk about what happened." 2. "I'll report the technician to the head of the radiology department." 3. "The technician never should have said that to you." 4. "Your health care provider will discuss treatment options with you."
1
A client who is 24-hours postoperative bowel resection is receiving IV opioids for severe pain. The nurse reviews the health care provider's (HCP's) prescription to discontinue the continuous IV fluids and advance the diet from clear liquids to regular diet as tolerated. What is the nurse's most appropriate action? 1. Apply a saline lock adaptor 2. Contact the HCP to request a prescription for a saline lock 3. Remove the IV catheter 4. Slow the IV fluids to a keep-vein-open rate
1
The community health nurse is preparing to teach a group of African American women about prevention of diseases common to their ethnic group. Based on the incidence of disease within this group, which disorders should the nurse plan to discuss? Select all that apply. 1. Cervical cancer 2. Hypertension 3. Ischemic stroke 4. Osteoporosis 5. Skin melanoma
1,2,3
Which interventions does the nurse perform to promote normal rest and sleep patterns for a critically ill client? Select all that apply. 1. Dimming the lights at night 2. Increasing the level of continuous IV sedation during nighttime hours 3. Leaving the television on for diversion at night 4. Opening the window blinds/shades in the morning 5. Scheduling interventions and activities during the day when possible 6. Turning off equipment alarms in the client's room at night
1,4,5
Which positions are correct when caring for clients undergoing therapeutic procedures? Select all that apply. 1. High-Fowler's for a paracentesis in cirrhosis 2. Left side after liver biopsy in hepatitis 3. Semi-Fowler's after a cardiac catheterization 4. Sims for soap-suds enema administration 5. Supine position after lumbar puncture
1,4,5
An unlicensed assistive personnel (UAP) is aiding a client recovering from a right-sided cerebrovascular accident with resulting mild oropharyngeal dysphagia. The client has been placed on a dysphagia diet. Which actions require intervention by the registered nurse? Select all that apply. 1. The UAP adds milk to mashed potatoes to make them thinner 2. The UAP encourages the client to occasionally turn the head to the left 3. The UAP helps the client sit in an upright position 4. The UAP places food on the strong side of the client's mouth 5. The UAP puts a straw in a fruit smoothie to prevent spilling
1,5
A client is scheduled for coronary artery bypass surgery in the morning. In the middle of the night, the nurse finds the client wide awake. The client demonstrates symptoms of extreme anxiety and tells the nurse about wanting to refuse the surgery. Which statement by the nurse would be most appropriate? 1. "Please try not to worry, you have an excellent surgeon." 2. "Tell me about how you feel about your surgery." 3. "Why are you considering refusing the surgery?" 4. "You have the right to make your own decisions and can refuse the surgery."
2
The nurse plans care for a client who has a positive Romberg test. The nurse will prioritize which intervention? 1. Monitor gag and swallowing reflexes closely 2. Provide for client assistance with ambulation 3. Provide sensory stimulation 4. Speak at a normal volume while facing the client directly
2
A nurse is entering the most recent laboratory report of a client on the telemetry floor. The client is currently asymptomatic, and the telemetry monitor indicates sinus rhythm. Which of the following critical values is most likely due to laboratory error? 1. Blood urea nitrogen (BUN) of 60 mg/dL 2. Creatinine of 4.0 mg/dL 3. Potassium of 7.0 mEq/L 4. Sodium of 155 mEq/L
3
A postoperative client is prescribed IV patient-controlled analgesia (PCA) with morphine. The client tells the nurse, "I am pushing the button, but I'm still having a lot of pain." What is the priority nursing action? 1. Administer a bolus dose 2. Notify the health care provider (HCP) to request a higher dose 3. Perform a thorough pain assessment 4. Reinforce the proper use of the IV PCA pump
3
33 A client with advanced multiple sclerosis (MS) has been a resident in a nursing home for the past 2 years. One day, the client tells the nurse, "I want to get out of here and try living in my own home." What is the best response by the nurse? 1. "Do you have family or friends who could take care of you?" 2. "I'll make a referral to the local home care agency in your area." 3. "It will be very difficult to manage your care at home." 4. "Tell me how you think your life would be different if you moved from here."
4
A 25-year-old client is about to undergo a unilateral orchiectomy for treatment of testicular cancer. The client says to the nurse, "I'm so worried that my future spouse is going to call off our engagement." What is the best response by the nurse? 1. "Are you concerned about how the surgery will affect your sexuality?" 2. "If you are concerned about infertility, you could always bank your sperm." 3. "The cancer is at an early stage. You are going to be fine." 4. "What have you and your future spouse discussed about your condition?"
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An 8-year-old hospitalized due to a bowel obstruction is to be discharged home with a temporary colostomy. The parents' primary language is Vietnamese and their English proficiency is very limited. What is the best approach for the nurse to use when instructing the parents on how to care for the child at home? 1. Demonstrate the procedure using simple English phrases 2. Give the parents written instructions with picture illustrations 3. Tell the parents to have a friend or relative come in to translate 4. Use an interpreter via the telephone interpretation service
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An adult client has developed diarrhea 24 hours after the initiation of total enteral nutrition via nasogastric tube. The client is receiving a hypertonic formula. What is the best nursing action? 1. Dilute the formula with water 2. Discontinue the tube feeding 3. Send a stool sample to the lab for culture and sensitivity 4. Slow the rate of administration of the feeding
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An adult client is admitted with back pain and found to have a metastatic tumor on the spine. The health care provider (HCP) explains that the client has few months to live and is likely to become totally paralyzed below the waist soon. The next day, the client tells the nurse of wanting to be discharged despite the HCP's recommendation that the client stay a few more days. Which is the most appropriate initial response by the nurse? 1. "I understand your desire to leave, but it would be very risky." 2. "I will ask the palliative care nurse to talk with you to help clarify your care goals." 3. "I will let the HCP know that you want to be discharged and do everything I can to make it happen." 4. "Tell me more about your need to leave the hospital."
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