Fundamentals final exam prep

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as cases of constipation? (select all that apply) A. excessive laxative use B. ignoring the urge to defecate C. inadequate fluid intake D increased fiber in the diet E. increased activity

A. Excessive Laxative useB. ignoring urge to defecate C. inadequate fluid intake

A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process? A. I will determine the most important client problems that we should address B. I will review the past medical history on the clients record to get more information C. I will carry out the new prescriptions from the provider D. I will ask the client if their nausea has resolved

A. I will determine the most important client problems that we should address

A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was 6 hours ago. The prescription reads every 4 hr PRN. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process? A. assessment B. planning C. intervention D. evaluation

A. assessment

A charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the following clients should the nurse assign to the room closest to the nurses' station? A. a client who sustained a head injury and is having periods of confusion B. a client who reports severe migraine headache C. a client who has a suspected diagnosis of tuberculosis D. a client who has a history of atrial fibrillation and is on continuous ECG monitoring

A. client who sustained a head injury and having periods of confusion

A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? A. complete a fall risk assessment B. educate the client and family about fall risks C. eliminate safety hazards from the client's environment D. make sure the client uses assistive aids in their possession

A. complete a fall risk assessment

A nurse is beginning a complete bed bath for a client. After removing the client's gown and placing a bath blanket over the body, which of the following areas should the nurse wash first? A. face B. feet C. chest D. arms

A. face

A charge nurse is reviewing with a newly hired nurse the difference in manifestations of a localized vs systemic infection. Which of the following are manifestations of a systemic infection? select all that apply A. fever B. malaise C. edema D. pain/ tenderness E. increase in pulse and respiratory rate

A. fever B. malaise E. increase in pulse and respiratory rate

A client who has heat stroke will have which of the following? A. hypotension B. bradycardia C. clammy skin D. bradypnea

A. hypotension

A nurse is instructing a client who has diabetes mellitus about foot care. Which of the following guidelines should the nurse include? select all that apply A. inspect feet daily B. use moisturizing lotion on the feet C. wash the feet with warm water and let them air dry D. use over the counter products to treat abrasions E. wear cotton socks

A. inspect feet daily B. use moisturizing lotion on the feet E. wear cotton socks

By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? A. Reassess the client to determine the reasons for inadequate pain relief. B. Wait to see whether the pain lessens during the next 24 hr. C. Change the plan of care to provide different pain relief interventions. D. Teach the client about the plan of care for managing his pain.

A. reassess the client to determine the reasons for inadequate pain relief

A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (select all that apply) A. report of feeling pressure B. tenderness over symphysis pubis C. distended badder D. voiding 30 mL frequently E. Dysuria

A. report of feeling pressure B. tenderness over symphysis pubis C. distended bladder D. voiding 30ml frequently

The nurse is planning care for a pt who develops dyspnea and feels tired after completing morning care. Which of the following actions should the nurse include in the clients plan of care? A. schedule rest periods during morning care B. discontinue morning care for 2 days C. perform all care as quickly as possible D. ask a family member to come in to bathe client

A. schedule rest periods during morning care

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take? A. Secure the restraints using a quick release tie B. ensure four fingers fit under restraints to prevent constriction C. secure the restraints to the lowest bar on the side rail D. Anticipate removing the restraints every 4 Horus

A. secure the restraints using a quick release tie

A nurse provides a back massage as a palliative care measure to a client who is unconscious, grimacing and restless. Which of the following findings should the nurse identify as indicating a therapeutic response? (Select all that apply) A. shoulders droop B. facial muscles relax C. respiratory rate increases D. pulse is within expected range E. client draws his legs up into fetal position

A. shoulders droop B. facial muscles relax D. pulse is within expected range

A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take? A. suction tow to three times whit a 60 second pause between passes B. perform chest PT prior to suctions C. lubricate suction catheter tip with sterile saline D. hyperventilate the client on 100% oxygen prior to suctioning

A. suction two to three times with a 60 second pause between passes

A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? A. turn the client's head to the side B. place two fingers in the client's mouth to open it C. brush the client's teeth once per day D. inject a mouth rinse into the center of the client's mout

A. turn client's head to the side

a nurse is planning care for an older adult client who is at risk for developing pressure ulcer. which of the following interventions should the nurse use to help maintain the integrity of the client's skin? A. use a transfer device to lift the client up in bed B. apply cornstarch to keep sensitive skin areas dry C. massage the skin over the client's body prominences D. elevate the head of the bed no more than 45 degrees

A. use a transfer device to lift the client up in bed

A nurse is implementing a bowel training program for a client. For the program to be effective. the nurse should take the client to the toilet at which of the following times? A. When the client has the urge to defecate B. every 2 hours while the client is away C. immediately before the client has a meal D. after the client feels abdominal cramping

A. when the client has the urge to defecate

A nurse is caring for a client who has an NG tube. The nurse tests the pH of the secretions to determine that the tube is correctly place. Which of the following readings should the nurse expect? A. 6.0 B. 4.0 C. 7.0 D. 8.0

B. 4.0

A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take? A. adjust water temp to feel hot B. apply 4-5 ml of liquid soap to hands C. hold hands higher than elbows D. rub hands and arms to dry

B. Apply 4-5 ml of liquid soap to hands

A nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? A. I will place the client on their side B. I will go to the nurses' station for assistance C. I will note the time that the seizure begins D. I will prepare to insert an airway

B. I will go to the nurses' station for assistance

A nurse is teaching a client who reports insomnia about promoting rest and sleep. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. I will walk briskly for 30 minutes before bed B. I will no longer have a glass of wine before bed time C. I will have a cup of hot cocoa immediately before bedtime D. I will do my muscle relaxation techniques each afternoon

B. I will no longer have a glass of wine before bedtime- can act as diuretic and disrupt sleep cycle

A nurse instructs a female client about collecting a midstream urine sample. Which of the following client states indicates an understanding of the procedure? A. I'll urinate a little then stop B. I'll use the cleansing wipe from from front to back C. I;ll clean the inside of the container with a wipe D. I'll use each cleansing wipe twice

B. I'll use the cleansing wipe from front to back

A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.) A. The provider drops a sterile instrument onto the near side of the sterile field. B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hr because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse. E. The client's hand brushes against the outer edge of the sterile field.

B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hr because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse.

A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first? A. call the client's provider B. assess client C. notify the nurse manager D. complete incident report

B. assess client

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for: A. steoatorrhea B. blood C. bacteria D. parasites

B. blood

A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the clients pain? A. vital signs measurement B. the client's self report of pain C. visual observation for nonverbal signs of pain D. the nature and invasiveness of the surgical procedure

B. client's self report

A nurse is receiving change of ship report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process? A. critically analyze client data to determine priorities B. collect and organize client data C. set client centered, measurable and realistic goals D. Determine effectiveness of interventions

B. collect and organize client data

a nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to inability to swallow. Which of the following is the priority action by the nurse? A. observe client's respiratory status B. elevate the head of client's bed from 30 to 45 C. Monitor intake and output every 8 hours D. Check residual volume every 4-6 hours

B. elevate head of bed from 30 to 45 degrees to reduce risk of aspiration

A nurse is caring for a client who has active pulmonary tuberculosis. The client requires airborne precautions and is receiving multi drug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiologic department for a chest x-ray? A. ask x-ray tech to come to clients room to obtain portable x-ray B. have client wear a mask C. notify the x-ray department that the client requires airborne precautions D. wear a filtration mask and gloves during transport

B. have client wear a mask

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take? A. place the wheelchair at a 90 degree angle to the bed B. lock the wheels of the bed and the wheelchair C. acquire the help of several people to lift the client D. elevate the bed to a position of comfort for the nurse

B. lock the wheels of the bed and wheelchair

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? A. call family and ask them to stay with client B. move client to room closer to nurses' station C. apply wrist and leg restraints to client D. administer medication to sedate client

B. move client closer to nurses' station

A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions? A. Excessive thirst and urination B. Shakiness and diaphoresis C. fever and chills D. hypertension and crackles

B. shakiness and diaphoresis

A nurse is reviewing hand hygiene techniques with a group of assistive personnel. Which of the following instructions should the nurse include when discussing hand washing? select all that apply A. apply 3-5 mL of liquid soap to dry hands B. wash the hands with soap and water for at least 15 seconds C. rinse the hands with hot water D. use a clean paper towel to turn off hand faucets E. allow the hands to air dry after washing

B. wash hands with soap and water for at least 15 seconds D. use a clean paper towel to turn off hand faucets

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include? (select all that apply) A . place the client in a room that has negative air pressure of at least six exchanges per hour B. wear a mask when providing care within 3 ft of the client C. place a surgical mask on the client if transportation to another department is unavoidable D. use sterile gloves when handling soiled linens E. wear a gown when performing care that might result in contamination from secretions

B. wear a mask when providing care within 3 ft of the client C. place a surgical mask on the client if transportation to another department is unavoidable E. wear a gown when performing care that might result in contamination from secretions

A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? select all that apply A. writing a prescription for morphine sulfate as needed for pain B. inserting a NG tube to relieve gastric distension C. Showing a client how to use progressive muscle relaxation D. performing a daily bath after the evening meal E. repositioning a client every 2hr to reduce pressure injury risk

C. Showing a client how to use progressive muscle relaxation D. performing a daily bath after the evening meal E. repositioning a client every 2hr to reduce pressure injury risk

A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (Select all that apply.) A. A bottle containing a sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand

C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand

A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions? A. upper respiratory infections B. pulmonary edema C. atelectasis D. delayed gastric emptying

C. atelectasis- from prolonged bed rest

A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunch tray? A. lemon sherbet B. plain yogurt C. cranberry juice D. carrot juice

C. cranberry juice

A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (select all that apply) A. place a belt restraint on the client when they are sitting on the bedside commode B. keep the bed in its lowest position with all side rails up C. make sure that the client's call light is within reach D. provide the client with nonskid footwear E. complete a fall risk assessment

C. make sure that the client's call light is within reach D. provide the client with nonskid footwear E. complete a fall risk assessment

A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority? A. extinguish fire B. activate fire alarm C. move clients who are nearby D. close all open doors on the unit

C. move clients who are nearby

A nurse is preparing a sterile field. Which of the following actions should the nurse identify as contaminating the field? A. Placing a sterile dressing 5cm (2in) from the border of the sterile field B. holder a sterile item at just above waist level C. Opening a sterile package over the middle of the sterile field D. Opening the sterile tray by first unfolding the flap farthest from his body

C. opening a sterile package over the middle of sterile field

When entering client's room to change dressing, nurse notes client is coughing & sneezing. Which of the following actions should the nurse take when preparing the sterile field? A: keep sterile field at least 6 ft away from client's bedside B: instruct client to not cough/sneeze during dressing change C: place mask on client to limit spread of microorganisms into surgical wound D: keep box of Kleenex nearby for client to use during dressing change

C. place a mask on the client to limit the spread of micro organisms into the surgical wound

A nurse is admitting a client who is arriving back to the unit from the PACU following hips arthroplasty. Which of the following tasks should the nurse assign the the AP? A. obtain initial vital signs B. determine if the client is in need of pain medication C. record amount of urine in the catheter drainage bag D. Instruct client on use of incentive spirometer

C. record amount of urine

A nurse is administering a cold therapy application to a client. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? A. hypotension B. numbness C. shivering D. reduced blood viscosity

C. shivering

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take? A. use a stiff toothbrush to clean client's teeth B. Use a thumb and index finger to keep the client's mount open C. turn client on side before starting oral care D. apply petroleum jelly to client's lips after oral care

C. turn client on side before starting oral care

a nurse is caring for a client who has 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? A. wear N95 respirator mask B. wear sterile gloves C. wear clean gloves D. Wear protective eyewear

C. wear clean gloves

a nurse is caring for a client who has an indwelling urinary catheter and notes blood tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations? A. Pernicious anemia B. Dehydration C. Prostate enlargement D. Bladder infection

D. Bladder infection

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered? A. creatine kinase B. troponin C. total bilirubin D. albumin

D. albumin

A nurse is ready to insert an indwelling urinary catheter for a female client. Which of the following instructions should the nurse give the client as the catheter is inserted? A. contract pelvic muscles B. take a sip of water C. exhale slowly D. bear down

D. bear down

A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. which of the following information should the nurse include? A. carbon monoxide has a distinct odor B. water heaters should be inspected every 5 years C. the lungs are damaged from carbon monoxide inhalation D. carbon monoxide binds with hemoglobin in the body

D. carbon monoxide binds with hemoglobin in the body

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take? A. Mix three meds together prior to administering B. Dilute each medication with 10ml of tap water C. Maintain head of bed in.a flat position for 30 minutes following med administration D. flush NG tube with 30 ml of water immediately following med administration

D. flush NG tube

A nurse is caring for a client who reports difficulty sleeping while in the hospital. Which of the following actions take by the assistive personnel while the client is sleeping should prompt the nurse to intervene? A. closes door to client's room B. Measures the client's vital signs routinely C. asks a group of nurses in the hall to speak quietly D. Flushes the client's toilet after emptying the urinary catheter's drainage bag

D. flushes client's toilet

A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plant to use to prevent the client from developing plantar flexion contractors? A. trochanter roll B. sheepskin heel pad C. abduction pillow D. foot board

D. footboard

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? A. confirm placement B. remove gastric acid that might cause dyspepsia C. determine the client's electrolyte balance D. identify delayed gastric emptying

D. identify delayed gastric emptying- if delayed should avoid feeding and causing distention

A nurse discovers a small paper fire in a trash can in a client's bathroom. The client has been take to safety and the alarm has been activated. Which of the following actions should the nurse take? A. open the windows in the client's room to allow smoke to escape B. obtain a class C fire extinguisher to extinguish the fire C. remove all electrical equipment from the client's room D. place wet towels along the base of the door to the client's room

D. place wet towels along the base of the door to the client's room

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first? A. administer oxygen B. administer prescribed analgesic medication C. encourage coughing and deep breathing D. raise the head of bed

D. raise the head of bed- allows for increased expansion of lungs

A nurse is caring for a client who needs a stool specimen collected. Which of the following actions should nurse take when obtaining the specimen? A. use sterile swab to obtain the specimen B. place specimen in sterile container C. Label the paper bag in which specimen container is placed D. send specimen container immediately to the lab

D. send specimen immediately to lab

A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closest to the body B. The right side flap C. The left side flap D. The flap farthest from the body

D. the flap farthest from the body

A nurse is caring for a client who has fallen while getting out of bed and states "I'm okay. I guess I should have called for help to the bathroom." After assessing the client, the nurse notifies the provider. Which of the following documentation should the nurse include in the client's medical record? A. there were no injuries sustained B. an incident report was completed C. an incident report was forwarded to risk management D. The provider was notified

D. the provider was notified

a nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use? A. one nurse lifting as the client pushes with his feet B. two nurses lifting the client under the shoulders C. one nurse lifting the client's legs as the client uses a trapeze bar D. two nurses using a friction reducing device

D. two nurses using a friction reducing device

A home heath nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? (select all that apply) A. bathtub with rails B. electric cords behind furniture C. raised toilet seats D. Water heater temp 130 F E. Throw rugs

D. water heater E. throw rugs

A nurse is providing discharge teaching for a client who has heart failure and is on a fluid restriction of 2000mL/day. The client asks the nurse how to determine the appropriate amount of fluids he is allowed. Which of the following statement is an appropriate response by the nurse? a "Pour the amount of fluid you drink into an empty 2-liter bottle to keep track of how much you drink" b "Each glass contains 8 ounces. There are 30 milliliters per ounce so you can have a total of 8 glasses or cups of fluid each day" c "This is the same as 2 quarts or about the same as two pots of coffee" d " Take sips of water or ice chips so you will not take in too much fluid"

a. "Pour the amount of fluid you drink into an empty 2-liter bottle to keep track of how much you drink"

A nurse is preparing to administer a medication to a patient. The medication was scheduled for administration at 0900. Which of the following are acceptable administration times for this medication? (Select all that apply) a 0905 b 0825 c 1000 d 0840 e 0935

a. 0905 d. 0840

A nurse in a provider's office is caring for a patient who states that, for the past week, she has felt tired during the day and cannot sleep at night. Which of the following questions should the nurse ask when collecting data about the patient's difficulty sleeping. (Select all that apply) a Does your lack of sleep interfere with your ability to function during the day? b Do you feel confused in the late afternoon? c Do you drink coffee tea or other caffeinated drinks? If so how many cups per day? d Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep? e Tell me about your personal stress you are experiencing

a. Does your lack of sleep interfere with your ability to function during the day? c. Do you drink coffee tea or other caffeinated drinks? If so how many cups per day? d. Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep? e. Tell me about your personal stress you are experiencing

Which action by the nurse most likely represents a situation of assault? a In the emergency room, the patient is intoxicated and verbally abusive. The nurse informs the patient restraints will be used if the behavior doesn't cease. b The patient is in labor and has not received any medications for pain. The patient continues to refuse any pain medications. The nurse administers the pain medication ordered. c The patient is planning to leave the unit against medical advice. The nurse states it is not in the patient's best interest given the medical condition and will call security if needed d The patient's church pastor calls the unit regarding the patient's condition. The nurse provides the clergyman with an update on the patient's condition.

a. In the emergency room, the patient is intoxicated and verbally abusive. The nurse informs the patient restraints will be used if the behavior doesn't cease.

A nurse prepares an injection of morphine (Duramorph) to administer to a patient who reports pain. Prior to administering the medication, the nurse is called to another room to assist another patient onto a bedpan. She asks the second nurse to give the injection. Which of the following actions should the second nurse take? a Offer to assist the patient needing the bedpan. b Administer the injection prepared by the other nurse. c Prepare another syringe and administer the injection. d Tell the patient needing the bedpan she will have to wait for her nurse.

a. Offer to assist the patient needing the bedpan.

A nurse is caring for a client who is to receive a full liquid diet due to dysphagia. Which of the following nursing actions is the highest priority? a Add thickener to liquids b Educate the client about acceptable liquids c Perform a calorie count of consumed liquids d Offer high- protein liquid supplements

a. add thickener to liquids

A physician orders an indwelling urinary catheter for a client who is mildly confused and has been combative. How should the nurse proceed? a Ask a colleague for help because the nurse cannot safely perform the procedure alone. b Gather the equipment and prepare it before informing the client about the procedure. c Obtain an order to restrain the client before inserting the urinary catheter. d Inform the primary provider that the nurse cannot perform the procedure because the client is confused

a. ask a colleague for help because the nurse cannot safely perform the procedure alone

The nurse has just completed wound care on her patient who has a large abdominal wound. What should the nurse do soon after this is completed? Select all that apply. a Assess the patient's response to the procedure b Teach the patient about the procedure c Document the procedure in the nursing progress notes d Ask the patient to assist in the wound care at the next scheduled dressing change

a. assess patient response to procedure c. document procedure in nursing progress notes

Post-op, the patient is receiving morphine via the patient controlled analgesia pump (PCA). The nurse finds the patient drowsy, with Temp 97.2 F, pulse 52, RR 11, BP 101/58 and pulse ox 93% on 2L of oxygen. Which action should the nurse take first? a Attempt to arouse the patient b Contact the health care provider c Check the PCA pump setting and history d Document the findings

a. attempt to arouse the patient

A nurse is teaching a client about high-fiber foods that can assist in lowering LDL. Which of the following foods should be included in the teaching? (Select all that apply) a Beans b Cheese c Whole grains d Broccoli e Yogurt

a. beans c. whole grains d. broccoli

A client is admitted to the hospital with an acute respiratory problem resulting from lung disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations. Which nursing intervention should be listed first on the care plan? a Determine airway adequacy hourly and as needed. b Administer oxygen as needed. c Monitor arterial blood gas values. d Place the client in a high Fowler's position.

a. determine airway adequacy hourly and as needed For any acute respiratory problem, prior to implementing interventions, the nurse would assess breathing status of the patient by checking the respiratory rate and depth. When devising a plan of care for the client, nursing interventions should be listed according to priority. Airway always takes precedence, as ventilation, oxygenation, and positioning will be ineffective without a patent airway.

A nurse is caring for an 80-year-old patient of Chinese heritage. When planning outcomes for this patient, which actions by the nurse would meet the American Nurses Association standards for outcomes identification? Select all that apply. a Developing culturally appropriate outcomes b Using the standardized outcomes on the clinical pathway c Choosing the best outcome for the patient regardless of the cost d Involving the patient and family in formulating the outcomes

a. developing culturally appropriate outcomes d. involving the patient and family in formulating the outcomes

Which are complications of bed rest? Select all that apply. a Extremity contractures b Decreased dependency c Diarrhea d Pneumonia e Pressure ulcers f Thrombi g Urinary Calculi

a. extremity contractures d. pneumonia e. pressure ulcers f. thrombi g. urinary calculi

A nurse is teaching a patient how to administer medications through a jejunostomy tube. Which of the following instructions should the nurse include in the teaching? a "Flush the tube before and after each medication." b "Administer your medications with your enteral feeding." c "Administer tablets through the tube slowly." d "Mix all the crushed medications prior to dissolving in water."

a. flush the tube before and after each med

TPN is prescribed for a patient with Chron's disease. What indicates to the nurse that the TPN has been effective? a Has met nutritional needs b Is not in metabolic acidosis c Is hydrated d Is in negative nitrogen balance

a. has met nutritional needs

A nurse is caring for a client with dysphagia and has a new dietary prescription. Which of the following should the nurse include in the plan of care? (Select all that apply) a Have suction equipment available for use b Use thickened liquids c Place food on the client's unaffected side of her mouth d Assign an assistive personnel to feed the client slowly e Teach the client to swallow with her neck flexed

a. have suction equipment available for use b. use thickened liquids c. place food on the client's unaffected side of her mouth e. teach the client to swallow with her neck flexed

What is wrong with the following diagnostic statement? "Impaired Physical Mobility related to laziness and not having appropriate shoes." The statement is: a Judgmental b Too complex c Legally questionable d Without supportive data

a. judgmental

A nurse is assessing a client who is in respiratory distress. The nurse should recognize that which of the following can cause a low pulse oximetry reading? (select all that apply) a Nail polish b Inadequate peripheral circulation c Hyperthermia d Increased hemoglobin level e Edema

a. nail polish b. inadequate peripheral circulation e. edema

Who is responsible for evaluating the outcome of a task delegated to the nursing assistive personnel (NAP)? a Nurse who delegated the task b LPN working with the NAP c Unit nurse manager d Charge nurse for the shift

a. nurse who delegated the task

A nurse is performing a nutritional assessment on a client. Which of the following clinical findings are suggestive of malnutrition? (Select all that apply) a Poor wound healing b Dry hair c Blood pressure 130/80mg Hg d Weak hand grips e Impaired coordination

a. poor wound healing b. dry hair d. weak hand grips e. impaired coordination

A nurse is assess the pain level of a client who has come to the emergency department reporting severe abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. The nurse is assessing which of the following? . a Presence of associated symptoms b Location of the pain c Pain quality d Aggravating and relieving factors

a. presence of associated symptoms

A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? select all that apply A. respiratory rate is 22/min B. the client's partner states, "They said they hurt after walking about 10 minutes" C. The client's pain rating is 3 on a scale of 0-10 D. The client's skin is pink, warm and dry E. the assistive personnel reports that the client walked with a limp

a. respiratory rate is 22/min d. client's skin is pink, warm and dry e. the assistive personnel reports that the client walked with a limp

A nurse is assessing a client who has an acute respiratory infection that places her at risk for hypoxemia. Which of the following findings are early indicators that should alert the nurse that the patient is developing hypoxemia? Select all that apply a Restlessness b Tachypnea c Bradycardia d Confusion e Pallor

a. restlessness b. tachypnea d. confusion e. pallor

The client was found lying on the floor next to the bed. Once urgent care is provided, the nurse completes an incident report. Which statements would be inappropriate to include in the report? Select all that apply a. the client fell out of bed b. no bruises or injuries are noted on the client c. the client apparently climbed over the side rails when the nurse was out of the room d. the physician was notified that the client was found lying on the floor next to the bed e. the client is alert and oriented and stated that he needed to "go to the bathroom and didn't want to bother the nurse" f. vital signs are: temp 98.6; pulse 78bpm and regular; respirations 16 and regular; BP 118/78 mmHg

a. the client fell out of bed c. the client apparently climbed over the side rails when the nurse was out of the room

A school nurse is teaching a group of students how to read food labels. Which of the following should be included in the teaching? (select all that apply) a Total carbohydrates b Total fat c Calories d Magnesium e Dietary fiber

a. total carbs b. total fat c. calories e. dietary fiber

Which of the following describes the difference between dehiscence and evisceration? a With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site. b Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent c Dehiscence involves the protrusion of internal viscera from the incision site; with evisceration, there is a separation of one or more layers of wound tissue. d Dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to dermal tissue.

a. with dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal visceral from the incision site

A nurse is teaching a group of clients about influenza. Which of the following statements by a client requires clarification? a "I should wash my hands after blowing my nose to prevent spreading the virus" b "I need to avoid drinking fluids if I develop symptoms" c "I need a flu shot every year because of the different flu strains" d " I should sneeze into my elbow rather than my hands"

b. "I need to avoid drinking fluids if I develop symptoms"

A nurse is caring for a client who has chronic venous insufficiency. The provider prescribed thigh-high compression stockings. The nurse should instruct the client to a Massage both legs firmly with lotion prior to applying the stockings b Apply the stockings in the morning upon awakening and before getting out of bed c Roll the stockings down to the knees if they will not stay up on the thighs. d Remove the stockings while out of bed for one hour, four times a day to allow the legs to rest.

b. Apply the stockings in the morning upon awakening and before getting out of bed

The nurse is preparing to insert a Foley catheter for her patient. What is the best strategy for the nurse to use to perform this insertion in a timely and efficient manner? a Call another nurse to assist with the procedure b Gather all supplies and equipment before entering the patient room c Instruct and explain the procedure to the patient d Check the patient's schedule for the day for the most convenient time

b. Gather all supplies and equipment before entering the patient room

The nurse is reviewing hand hygiene with UAPs. Which statement by the UAP requires further instructions? a "I will wash my hands before and after care and I wear gloves with each patient." b "I wash my hands when they are visible soiled." c "I will not wear artificial nails when providing care." d "It is OK to use the alcohol based products outside of the patient's room when entering and leaving the area."

b. I wash my hands when they are visibly soiled

A nurse is providing teaching to an older adult patient to promote adherence with medication administration. Which of the following instructions should the nurse include? (Select all that apply) Multiple answers: Multiple answers are accepted for this question Select one or more answers and submit. For keyboard navigation...SHOW MORE a Adjust the dose according to daily weight. b Place pills in daily pill holders. c Provide liquid forms if the patient has difficulty swallowing pills. d Ask a relative/friend to assist periodically e Request child-guard caps on medication containers.

b. Place pills in daily pill holders. c. Provide liquid forms if the patient has difficulty swallowing pills. d. Ask a relative/friend to assist periodically

What should the nurse do to prevent catheter-associated urinary tract infection? Select all that apply. a Change the catheter daily b Provide perineal care at least once a day c Maintain a closed drainage system d Encourage the patient to drink 3000 mL fluids daily e Recommend health care provider prescribe antibiotics

b. Provide perineal care at least once a day c. Maintain a closed drainage system d. Encourage the patient to drink 3000 mL fluids daily

Which of the following examples includes both objective and subjective data? a The patient's blood pressure reading is 132/68 mm Hg and heart rate is 88 beats/min. b The patient's cholesterol is elevated, and he states he likes fried food. c The patient states she has trouble sleeping and that she drinks coffee in the evening. d The client states he gets frequent headaches and that he takes aspirin for the pain.

b. The patient's cholesterol is elevated, and he states he likes fried food.

A nurse is caring for several clients in an extended care facility. Which of the following clients is the highest priority to observe during meals? a A client who has decreased vision b A client who has Parkinson's disease c A client who has poor dentition d A client who has anorexia

b. a client who has parkinson's

You are a nurse working in the college student health center. You receive a call that an athlete has just fallen and has been injured. You know that according to the general adaptation syndrome, the athlete will be exhibiting: a An increased appetite b An increased heart rate c A decrease in perspiration d A decrease in respiratory rate

b. an increased heart rate

When preparing a sterile field, which condition indicates to the nurse the field is at risk for contamination? a The dressing is laying 3 inches away from the border of the sterile field b An opened sterile package is placed into the middle of the sterile field c A sterile item is held above waist level and in eye sight d Clean gloves are used to pore sterile saline into the sterile cup

b. an opened sterile package is placed into the middle of the sterile field

A nurse is caring for a client who has heart failure and reports increased shortness of breath. The nurse increases the oxygen per protocol. Which of the following actions should the nurse take first? a Obtain the client's weight b Assist the client into High-fowler's position c Auscultate lung sounds d Check oxygen saturation with pulse oximeter

b. assist the client into high-fowler's position

A nurse is caring for a patient who is having difficulty breathing. The client is lying in bed and already receiving oxygen via nasal cannula. Which of the following interventions is the nurse's priority? a Increase the oxygen b Assist the client to Fowler's position c Promote removal of pulmonary secretions d Obtain a specimen for arterial blood gas

b. assist the client to fowler's position

A patient admitted with pneumonia and dementia has attempted several times to pull out the IV and Foley catheter. After trying other options, the nurse obtains a prescription for bilateral soft restraints. Which nursing action is most appropriate? a Perform circulation checks to bilateral upper extremities each shift b Attach the ties of the restraints to the bed frame c Reevaluate the needs for restraints and document weekly d Ensure the restraint prescription has been signed by the health care provider (HCP) within 72 hours

b. attach the ties of the restraints to the bed frame

When teaching the patient with a urinary tract infection about taking a prescribed antibiotic for 7 days, the nurse should tell the patient to report which symptoms to the health care provider (HCP)? Select all that apply. a Cloudy urine for the first few days b Blood in the urine c Rash d Mild nausea e Fever above 100 degrees F (37.8 degrees C) f Urinating every 3 to 4 hours

b. blood in the urine c. rash e. fever above 100 degrees F

A nurse is working with a newly hired nurse who is administering medications to patients. Which of the following actions by the newly hired nurse indicates an understanding of medication error prevention? a Taking all medications out of the unit-dose wrappers before entering the patient's room. b Checking with the provider when a single dose requires administration of multiple tablets. c Administering a medication, then looking up the usual dosage range. d Relying on another nurse to clarify a medication prescription.

b. checking with he provider when a single dose requires administration of multiple tablets

The nurse works with the respiratory therapist to administer a patient's breathing treatments. He reports the patient's breathing status and tolerance of the treatment to the primary care provider. The nurse then discusses with the patient the options for further treatment. This is an example of: a Delegation b Collaboration c Coordination of care d Supervision of care

b. collaboration

A patient is using biofeedback to manage pain. The nurse can explain to the client that biofeedback will enable the patient to exert control over physiologic processes by which mechanism? a Regulating the body processes through electrical control b Shocking the patient when an undesirable response is elicited c Monitoring the body processes for the therapist to interpret d Translating the signals of body processes into observable forms

b. document the patient's response to pain medication

A nurse is screening a client for hypertension. Which of the following actions by the client increase his risk for hypertension? (Select all that apply) a Drinking 8oz of nonfat milk daily b Eating popcorn at the movie theater c Walking 1 mile daily at 12 min/mile pace d Consuming 36 oz of beer daily e Getting a massage once a week

b. eating popcorn at the movie theater d. consuming 36 oz of beer daily

Total parenteral nutrition (TPN) is prescribed for the patient who has recently had a small and large bowel resection and who is currently not taking anything by mouth. What should the nurse do to safely administer the TPN? a Administer TPN through a nasogastric or gastrostomy tube b Handle TPN using strict aseptic technique c Auscultate for the presence of bowel sounds prior to administration of TPN d Designate a peripheral IV site for TPN administration

b. handle TPN using strict aseptic technique

The nurse should perform passive range-of-motion (ROM) exercises on which patients? Select all that apply Multiple answers: Multiple answers are accepted for this question a Has septic joints b Has temporary loss of consciousness c Is unconscious d Has plantar flexion of the foot e Has supination of the hand

b. has temporary loss of consciousness c. is unconscious

Which of the following is an example of a problem that nurses can treat independently? a Hemorrhage b Nausea c Fracture d Infection

b. nausea

Which statement related to prioritizing patient problems is most accurate? a Nurses must resolve one problem before addressing another problem. b Nurses prioritize problems in order of urgency. c Actual problem always take priority over risk problems. d Nurses give the highest priority to problems that the patient thinks are most important.

b. nurses prioritize problems in order or urgency

A nurse is caring for a client who has Alzheimer's Disease and falls frequently. Which of the following actions should the nurse take first to keep the client safe? a Keep the call light near the client. b Place client in a room close to the nurses' station c Encourage client to ask for assistance d Remind client to walk with someone for support

b. place client in a room close to the nurses' station

Which factor puts an older adult at the greatest risk for impaired wound healing after abdominal surgery? a Age over 75 years b Poorly controlled diabetes c History of one myocardial infarction d Chronic peripheral vascular disease

b. poorly controlled diabetes

A nurse is reviewing the laboratory findings for urinalysis (UA) of a client who reports urgency and nocturia. Which of the following findings should the nurse report to the provider? a Positive for casts b Positive leukocyte esterase c Positive for epithelial cells d Positive for crystals

b. positive for leukocyte esterase

Based only on Maslow's Hierarchy of Needs, which nursing diagnosis should have the highest priority? a Self-Care Deficit b Risk for Aspiration c Impaired Physical Mobility d Functional Urinary Incontinence

b. risk for aspiration

While assessing a new wound, the nurse notes red, watery drainage. How should the nurse describe this type of drainage when documenting? a Sanguineous b Serosanguineous c Serous d Purosanguineous

b. serosanguineous

A patient comes into the emergency department complaining of chest pain. When discussing possible reasons why the chest pain has occurred, the nurse learns that the patient is depressed because of the loss of a job. This type of crisis can be classified as: a Maturational b Situational c Sociocultural d Posttraumatic

b. situational

The nurse is assessing a hospitalized older patient for the presence of pressure ulcers. The nurse notes that the patient has a 1" by 1" (3cm by 3cm) area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the medical record? a Stage I pressure ulcer b Stage 2 pressure ulcer c Stage 3 pressure ulcer d Stage 4 pressure ulcer

b. stage 2 pressure ulcer

A patient suffers from sleep pattern disturbance. To promote adequate sleep, the most important nursing intervention is: a Administering a sleep aid b Synchronizing the medication, treatment, and vital signs schedule c Encouraging the patient to exercise immediately before sleep d Discussing with the patient the benefits of beginning a long-term nighttime medication regimen

b. synchronizing the medication, treatment, and vital signs schedule

A nurse is caring for an older adult client in an extended care facility. Which of the following indicates the client has a stool impaction causing a large intestine obstruction? a The client reports he had a bowel movement yesterday b The client is having small, frequent liquid stools c The client is flatulent d The client indicates he vomited once this morning

b. the client is having small, frequent liquid stools

A nurse is caring for a client who has dyspnea and is to receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? a Nonrebreather mask b Venturi mask c Nasal cannula d Simple face mask

b. venturi mask

A nurse is completing an assessment of a client who is a first generation immigrant to the U.S. Which of the following questions should the nurse consider asking to understand the client's culture-based nutrition habits? a "What type of afternoon snacks do you consume?" b "What type of meal do you prepare for a holiday?" c "What time of day do you eat breakfast?" d "What cooking utensils are used in food preparation?"

b. what type of meal do you prepare for a holiday

The nurse is teaching the patient how to care for an ileostomy. The patient asks the nurse how long to wear the pouch before changing it. What should the nurse tell the patient? a "The pouch is changed only when it leaks" b "You can wear the pouch for about 4 to 7 days>" c "You should change the pouch every evening before bedtime." d "It depends on your activity level and your diet."

b. you can wear the pouch for about 4-7 days

Which of the following nursing activities is most reflective of the evaluation phase of the nursing process? a Administering pain medication prior to changing a complex wound dressing b Obtaining patient's blood pressure 30 minutes after administering blood pressure medication c Reporting that there have been three patient falls in the past month on the nursing unit d Teaching the patient how to perform daily Accu-Cheks for blood sugar readings

b.Obtaining patient's blood pressure 30 minutes after administering blood pressure medication

Which statement by the nurse best demonstrates clear communication to nursing assistive personnel (NAP) about delegating a task? a "Record how the patient's intake and output of fluids, please" b "Take the patient's temperature, pulse, respirations, and blood pressure every 2 hours today." c "Take the patient's temperature every 4 hours; notify me if it is greater than 100.5°F (38.1°C)." d "Assist the patient with all of her meals so she will take in more calories."

c. "Take the patient's temperature every 4 hours; notify me if it is greater than 100.5°F (38.1°C)."

The nurse reviews a nursing order for a patient who is 4 days post-operative after hip surgery. It reads: Assist patient in bathing each morning. The nurse assesses the patient and notes that the patient is independent in bathing. What should the nurse do next? a Assist with the bath as ordered b Delegate the bath to the nursing assistant c Discontinue the nursing order on the plan of care d Collaborate with the nurse who originally wrote the order

c. Discontinue the nursing order on the plan of care

A nurse is instructing an assistive personnel in caring for a client who has a low platelet count and needs vital signs taken. Which of the following statements contain the correct instructions in this situation? a Count the patient's radial pulse for 60 seconds b Count the respiratory rate and tell the patient you are doing so c Do not take the patient's temperature rectally d Let the patient rest in between each vital sign for 5 minutes.

c. Do not take the patient's temperature rectally

The nurse is caring for a patient with bacterial pneumonia. The effectiveness of the patient's oxygen therapy can be best determined by which indicator of oxygenation? a Absence of cyanosis b Patient's respiratory rate c Arterial blood gas (ABG) values d Patient's level of consciousness

c. arterial blood gas (ABG) values

A provider is discharging a patient with a prescription for home oxygen therapy via nasal cannula. Which of the following should be included in the instructions? a Apply petroleum jelly around the nares b Assure the patient and their family that the patient can still smoke c Check the position of the nasal cannula frequently d Remove the nasal cannula during meal time

c. check the position of the nasal cannula frequently

A nurse is caring for a patient with a Foley catheter. What should the nurse do to reduce the risk of infection? a Clean the perineum with peroxide after each void b Decrease oral fluids. c Empty the Foley bag every 4 to 8 hours. d Open the bag and Foley system to check for kinks

c. empty the foley bag every 4-8 hours

The nurse is going to lunch and is conducting a "hand-off of care" to the charge nurse. Which information should the nurse communicate to the charge nurse during the "hand-off of care" communication? a Tell the charge nurse that the nurse is going to lunch b Verify that the charge nurse has assigned someone to take care of the patient c Give the charge nurse information about what care should be given while the nurse is at lunch d Remind the charge nurse about the patient's history and current medicaitons

c. give the charge nurse information about what care should be given while the nurse is at lunch

A patient has a colostomy in the descending (sigmoid) colon and wants to control bowel evacuation and possibly stop wearing an ostomy pouch. To help achieve this goal, the nurse should teach the patient to: a Avoid returning to the use of an ostomy appliance if he becomes ill. b Call the primary care provider if the stoma becomes pale, dusky, or black. c Irrigate the stoma to produce a bowel movement on a schedule. d Limit the intake of gas-forming foods such as cabbage, onions, and fish

c. irrigate the stoma to produce a bowel movement on a schedule

Which mental status change may occur when a patient with pneumonia is first experiencing hypoxia? a Coma b Apathy c Irritability d Depression

c. irritability

Which of the following is an example of an active listening behavior? a Taking frequent notes b Asking for more details c Leaning toward the patient d Sitting comfortably with legs crossed

c. leaning toward the patient

The nurse is assessing a client with dark skin for the presence of a stage 1 pressure ulcer (injury). Which is the best approach to making this assessment? a Use a fluorescent light source to assess the skin b Inspect the skin only when the Braden score is above 12 c Look for skin color that is darker than the surrounding tissue d Avoid touching the skin during inspection

c. look for skin color that is darker than the surrounding tissue

Which of the following is the best example of an outcome statement? The patient will: a Use the incentive spirometer when awake b Walk two times during day and evening shift c Maintain oxygen saturation above 92% while performing ADLs each morning d Tolerate 10 sets of range-of-motion exercises with physical therapy

c. maintain oxygen saturation above 92% while performing ADLs each morning

A 4-year-old pediatric patient resists going to sleep. To assist this patient, the best action to take would be: a Adding a daytime nap b Allowing the child to sleep longer in the morning c Maintaining the child's home sleep routine d Offering the child a bedtime snack

c. maintaining the child's home sleep routine

A nurse is caring for an Asian client who has hypertension. Which of the traditional Asian dietary patterns places the client at risk for this condition? a Incorporation of plant based foods in the diet b Consumption of raw fruits c Preparation of foods using sodium d A focus on shellfish in the diet

c. preparation of foods using sodium

A nurse is caring for a client who displays signs of Stage 3 Parkinson's disease. Which of the following actions should the nurse include in the plan of care? a Recommend a community support group b Integrate a daily exercise program c Provide a walker for ambulation d Consultation with a dietitian

c. provide a walker for ambulation

What is the correct method for turning an adult patient brought to the ER with a suspected spinal cord injury? . a Ask the patient to assist with the turn by holding the siderails of the bed b Place a draw sheet under the patient to assist with turning c Request help from another nurse to perform logrolling technique d Use a mechanical lift for safe turning and protecting the nurse's back

c. request help from another nurse to perform logrolling technique

The nurse has determined that the goal for a particular nursing diagnosis on the client's plan of care has not been met. It will be most important for the nurse to a Report this finding to the provider b Note this finding in the client's record c Revise the plan of care d Remove the nursing diagnosis from the plan

c. revise plan of care

A nurse is completing discharge teaching with a client who is 3 days post operative for a transverse colostomy. Which of the following should be included in the teaching? a Mucus will be present in stool for 5 to 7 days after surgery b Expect 500 to 1,000 mL of semi-liquid stool after 2 weeks c Stoma should be pink and moist d Change the ostomy bag when it is ¾ full

c. stoma should be pink and moist

Which patient has a naturally acquired active immunity? a The adult who received immunizations b The infant whose immunity was transferred from the mother to the infant. c The child is recovering from a childhood disease that conferred immunity. d The adult who received gamma globulin after exposure to Hepatitis.

c. the child is recovering from a childhood disease that conferred immunity

A nurse is caring for a client who has cancer pain. Which of the following is the most reliable indication of the client's pain? a Change in pulse b Facial expression of pain c Verbal report of pain d Massaging an area of pain

c. verbal report of pain

A nurse is caring for a client who has cancer pain. Which of the following is the most reliable indicator of the client's pain? a Change in pulse rate b Facial expressions of pain c Verbal report of pain d Massaging an area of pain

c. verbal report of pain

The nurse receives the following report on four patients on the medical-surgical unit. Which patient will the nurse attend to first? a Gait unsteady, uses walker, needs 2-person assist with ambulation b Abdominal wound is draining foul-smelling fluid, incision margins are red, heart rate 100 beats/min c Blood pressure 90/50 mm Hg, heart rate 40 beats/min, rates chest pain at 8 on a 0 to 10 pain scale d Verbalizes history of migraine headaches, eyes closed during assessment interview

c.Blood pressure 90/50 mm Hg, heart rate 40 beats/min, rates chest pain at 8 on a 0 to 10 pain scale

Which nursing diagnosis is written in the correct format when using the NANDA-I taxonomy? a Bowel Obstruction related to recent abdominal surgery AMB: nausea, vomiting, and abdominal pain b Inability to Ingest Food related to imbalanced nutrition: less than body requirements A.M.B. inadequate food intake, weight less than 20% under ideal body weight c Impaired Skin Integrity related to physical immobility AMB skin tear over sacral area d Caregiver Role Strain related to alienation from family and friends AMB 24-hour care responsibilities

c.Impaired Skin Integrity related to physical immobility AMB skin tear over sacral area

A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements made by the client indicates an understanding of the teaching? a "I will place the adapter on my finger to read my blood oxygen saturation level." b "I will lie on my back with my knees bent." c " I will rest my hand over my abdomen to create resistance." d " I will take in a deep breath and hold it before exhaling."

d. I will take in a deep breath and hold it before exhaling

Which of the following is the best example of the implementation phase of the nursing process? a Patient verbalizes pain is reduced from an 8 to a 3 after receiving pain medication. b Nurse observes that patient has a small, quarter-sized skin tear over coccyx area. c Nurse writes in the care plan: Patient requires 2 person assist with ambulation to bathroom. d Nurse inserts Foley catheter after reporting to physician patient's inability to void.

d. Nurse inserts Foley catheter after reporting to physician patient's inability to void.

The nurse is called to the patient's room by another nurse. When the second nurse arrives at the room, she discovers that a fire has occurred in the patient's waste basket. The first nurse has removed the patient from the room. What is the second's nurse next action? a Evacuate the unit b Extinguish the fire c Confine the fire d Activate the fire alarm

d. activate the alarm

A nurse is discussing foods that are high in Vitamin D with a client who is unable to be out in the sunlight. Which of the following should be included in the teaching? a Tacos and Rice b Hamburgers and fried potatoes c Ham and Brussels Sprouts d Eggs and Fortified Milk

d. eggs and fortified milk

A nurse makes a nursing diagnosis of Acute Pain related to the postoperative abdominal incision. She writes a nursing order to reposition the client in a comfortable position using pillows to splint or support the painful areas. What type of nursing intervention did the nurse write? a Collaborative b Interdependent c Dependent d Independent

d. independent

When coping becomes dysfunctional enough to require the client to be admitted to the hospital, the nurse expects that the client would be exhibiting what behaviors? a Objective and rational problem solving b Tension reduction activities and then problem solving c Anger management strategies with no problem solving d Minimal functioning with new problems developing

d. minimal functioning with new problems developing

The nurse must transfer a dependent patient from a bed to a gurney. Which action by the nurse will be safest for the patient and nurse? a Adjust the height of the bed b Avoid movements that twist the spine c Keep the patient close to the nurse's body when lifting d Obtain an appropriate mechanical lift device

d. obtain an appropriate mechanical lift device

A nurse is obtaining a history from a client who has pain. The nurse's guiding principles throughout this process should be that a Some clients exaggerate their pain level b Pain must have an identifiable source to justify the use of opioids c Objective data are essential in assessing pain d Pain is whatever the client says it is

d. pain is whatever the client says it is

A nurse is assessing a client who is postoperative following a colon resection. Which of the following findings indicates that the client is ready to transition from NPO to oral intake? a Client report of hunger b Urinary output exceeding 30 mL/hr c Decrease in incisional pain d Passage of flatus

d. passage of flatus

Which intervention should the nurse take first to promote the start of urination in a patient who is having difficulty voiding? a Insert an intermittent, straight catheter b Insert an indwelling urinary catheter c Notify the provider immediately d Pour warm water over the patient's perineum

d. pour warm water over the patient's perineum

During rounds on the night shift, you note that a patient stops breathing for 1 to 2 minutes several times during the shift. This condition is known as: a Cataplexy b Insomnia c Narcolepsy d Sleep apnea

d. sleep apnea

A nurse is caring for a client who is dehydrated. Which of the following clinical manifestations should the nurse assess for that is indicative of fluid volume deficit? a Moist skin b Distended neck veins c Increased urinary output d Tachycardia

d. tachycardia

Which skin assessment finding would cause the nurse to suspect dehydration in a middle-aged patient admitted to the hospital with diarrhea? a Edema b Hypothyroidism c Pallor d Tenting

d. tenting

During meal time the nurse notices the patient's hands are holding the throat. Which patient situation requires immediate action by the nurse? a The patient has a high-pitched inspiratory stridor b The patient is talking and gagging c The patient is coughing d The patient is not making any sounds

d. the patient is not making any sounds

A patient is using biofeedback to manage pain. The nurse can explain to the client that biofeedback will enable the patient to exert control over physiologic processes by which mechanism? a Regulating the body processes through electrical control b Shocking the patient when an undesirable response is elicited c Monitoring the body processes for the therapist to interpret d Translating the signals of body processes into observable forms

d. translating the signals of body processes into observable forms

The nurse is planning the care of a frail, immobile, elderly patient. Which of the following is the best treatment or prevention to protect the patient's skin? a Administer fluid boluses as directed by the healthcare provider b Assisting the patient to sit in a chair three times a day c Offering the patient six small meals a day d Turning the patient at least every 2 hours

d. turning patient at least every 2 hours

A nurse is preparing to feed a patient via NG tube. Which of the following is the nurse's highest priority before initiating the feeding? a Check the feeding container for expiration b Confirm the patient does not have diarrhea c Make sure the client is alert and oriented d Verify placement of the NG tube

d. verify placement of the NG tube