Fundamentals

A nurse accidently administers the wrong medication to a client, which results in a severe allergic reaction and prolongs the client's hospitalization. The client could rightfully sue the nurse for which of the following?

Malpractice

A nurse is teaching a client who has a history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instruction?

"I will place a bath seat in my shower to use when I bathe"

A nurse is filling out an incident report after finding a client lying on the floor. Which of the following information should the nurse include?

"The client was lying on the floor next to his bed"

A nurse is assessing a client's peripheral circulation. In which of the following locations should the nurse palpate to access the posterior tibial pulse?

*behind ankle*

A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first?

Assess the client

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process.

Assessment

An assistive personnel reports a client's vital signs as tympanic temperature 37.1C (98.8F), pulse 92/min, RR 18/min and BP 98/58 mm Hg. Which of the following vital signs should the nurse remeasure?

Blood Pressure

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

Checking the pupillary response to light

A nurse is receiving change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?

Collect and organize client data

A nurse is caring for a client in the orientation phase of the nurse-client relationship. Which of the following communication techniques should the nurse use during this phase?

Elicit information from the client

A nurse is caring for a group of clients on a medical-surgical unit. which of the following situations requires that the nurse wear gloves? (SATA)

Emptying urine from an indwelling urine collection bag Providing oral care Changing an ostomy pouch

A nurse is removing PPE after giving direct client care to a client who requires isolation. Which of the following PPE items should the nurse remove first?

Gloves

A nurse is caring for an older client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take?

Leave a nightlight on in the client's room

A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs?

Move the client to a room closer to the nurses' station

A nurse asks a client to share personal stories. Which of the following types of intervention is the nurse using to promote the development of the nurse-client relationship?

Narrative Interaction

A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data

Nausea

A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands and cannot talk. Which of the following actions should the nurse take?

Perform the Heimlich maneuver

A nurse is teaching a newly hired group of assistive personnel about infection-control measures on the unit. It is crucial for the nurse to remind the APs that which of the following is the most effective way to prevent the spread of pathogens during client care?

Performing hand hygiene frequently and consistently

A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? (SATA)

Teach the client to use the call light Keep the bed in the lowest position Place a fall-risk ID band on the client's wrist

A nurse is observing a client's nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles influencing non-verbal communication?

The client's sociocultural background influences nonverbal communication

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

Turn the client on his side before starting oral care

A nurse is using the communication principal of presence when establishing a collaborative relationship with a client. Which of the following actions should the nurse take?

Use attentive listening with the client

A nurse caring for a client is using active listening skills. Which of the following actions should the nurse take?

Use intermittent eye contact

A nurse is caring for a client who has a methicillin-resistant staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take?

Wear clean gloves