Holistic Exam #1
The nurse is conducting a class for nursing assistants. One of the students asks the nurse why blood pressure, pulse, and temperature are called "vital signs". Which of the following explanations would the nurse offer the student? "Because significant deviation from normal is not compatible with life." "The term has just evolved over time without a clear definition for why." "They are called vital signs because the blood pressure is very important." "They are called vital signs because they are the first things the nurse does when admitting a patient to the hospital."
"Because significant deviation from normal is not compatible with life."
The nurse is using the SOAP format of charting during a home visit to a new mother. Which of the following data should the nurse document under the "P" domain of this format? "Client states that she has diffuse breast tenderness." "Client's breasts appear engorged." "Client states that she is having difficulty getting her infant to latch." "Client referred to the health unit's drop-in breastfeeding clinic."
"Client referred to the health unit's drop in breastfeeding clinic."
A student is choosing her educational path and desires a nursing degree with a track that contains community nursing and leadership, as well as liberal arts. The student would best be suited in which type of program? Baccalaureate program Diploma nursing program Certification in a nursing specialty Licensed practical nursing program
Baccalaureate program
Which peripheral pulse site is generally used in emergency situations? Carotid Temporal Apical Radial
Carotid
During the course of any given day of work in the acute care setting, the nurse may need to perform which of the following roles? Select all that apply. Statistician Teacher Communicator Counselor Financier
Communicator, Counselor, Teacher
Which nursing action best exemplifies the nurse's role in promoting health? Administering a beta-adrenergic blocker and diuretic to a client who has a history of hypertension. Encouraging a group of junior high school students to engage in regular physical activity. Facilitating a support group for the friends and families of clients affected by stroke. Performing deep suctioning on a client who has a tracheotomy and copious secretions.
Encouraging a group of junior high school students to engage in regular physical activity
The nurse recognizes that immunizations are an example of: Illness prevention Facilitating coping with disability and death Health restoration Health promotion
Illness prevention
What does the R stand for in SBAR?
R - recommendations
The registered nurse communicates with the physical therapist that a client is now on strict bed rest due to bradycardia. Which statement best explains the standard exemplified by the nurse? The RN collects client data. The RN identifies outcomes. The RN coordinates care delivery. The RN analyzes client data.
The RN coordinates care delivery
Which pharmacologic considerations should the nurse contemplate before administrating parental medications? (Select all that apply.) The drug will be filtered through the liver. The drug will not be filtered through the liver. The adverse effects of the drugs can be more pronounced. Older adults and children should be monitored closely for drug effects. This route of drug administration will be through the gastrointestinal tract.
The drug will not be filtered through the liver. The adverse effects of the drugs can be more pronounced. Older adults and children should be monitored closely for drug effects.
Which of the following is the best example of client-centered approach to care? The nurse asks the client about his health goals. The nurse helps a client ambulate. The nurse asks the client what he would like to order from menu. The nurse drawing a blood sample from a client.
The nurse asks the client about his health goals
A registered nurse wishes to work as a nurse researcher. Which is true regarding nurse researchers? They tend to work in community health centers and long-term care units. They are responsible for the continued development and advancement of nursing. They serve as liaisons between staff members and directors of nursing. They usually have a baccalaureate degree in nursing
They are responsible for the continued development and advancement of nursing.
The student nurse is having difficulty feeling the pedal pulse of the client with a fractured leg. What should the nurse do next? Use the Doppler ultrasound device. Use the Bell side of the stethoscope to listen. Connect the client to the oxygen saturation monitoring device. Ask another student nurse to check it for him.
Use the Doppler ultrasound device
The RN is working with hospital administration to transform care at their facility. Which of the following nursing competencies will be critical for the nurse to utilize? Correctly utilize and troubleshoot high-tech equipment. Navigate the electronic medical records system. Work effectively in interdisciplinary teams. Do things the way they have always been done.
Work effectively in interdisciplinary teams
The nurse assesses that a client is shivering. Which intervention is most appropriate to prevent further stress on the body? applying a blanket providing warm fluids raising the room temperature applying a cooling blanket
applying a blanket
The nurse has inserted a peripheral intravenous catheter into a client. What is the appropriate action when a blood return is not obtained? Insert the IV catheter further. Begin infusing the IV fluid. Change the site of catheter insertion. Pinch IV tubing to prohibit initial infusion.
change the site of catheter insertion
Which client should not have a temperature assessed rectally? Client with diarrhea Client with a herniated disc Client with cancer Client with ALS
client with diarrhea
A client is scheduled for a CABG procedure. What information should the nurse provide to the client? "A coronary artery bypass graft will benefit your heart." "The CABG procedure will help identify nutritional needs." "A complete ablation of the biliary growth will decrease liver inflammation." "The CABG procedure will help increase intestinal motility and prevent constipation."
coronary artery bypass graft will benefit your heart
Which nurse to provider interaction correctly utilizes the SBAR format for improved communication? "I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg
dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin." "I am calling about the patient in room 212. He has new onset diabetes mellitus, and I wondered if you would like to adjust the sliding scale of insulin." "I am calling about Mr. Jones in room 212. His blood glucose is 250 mg/dL (13.875 mmol/L), and I think that is high." "I am calling about Mr. Jones who has diabetes mellitus. His blood sugar seems high, and I think he needs more insulin."/ "I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin."
A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin, which is a cardiac medication. The nurse can anticipate that the digoxin will do what? Decrease the blood glucose. Decrease the blood volume. Decrease the respiratory rate. Decrease the apical pulse.
decrease apical pulse
The mother of a toddler is deciding if she wants to allow her child to receive the recommended immunizations. The clinic nurse responds, "If you don't immunize your child you are jeopardizing the health of other children." What type of approach does this response indicate? authoritarian or belittling guilt inducement or approval
disapproval advocacy or enforcing rights dictatorial or bossing/ guilt inducemment or approval/disapproval
When administering a subcutaneous injection to a client, the needle pulls out of the skin when the skin fold is released. What would be the appropriate next action of the nurse in this situation? Pull out and discard the needle. Discard the equipment and start the procedure from the beginning. Engage safety shield on needle guard and discard needle appropriately. Document the incident and inform the primary care provider.
engage safety shield on needle guard and discard needle appropriately
Nurses today are faced with many adversities. Which challenges have led to the current nursing shortage? (Select all that apply.) heavier workloads and sicker clients client satisfaction surveys and insurance reimbursement hospital budgetary decline and nursing layoffs job dissatisfaction and stress continuing education requirements and increasing number of men in nursing
hospital budgetary decline and nursing layoffs, job dissatisfaction and stress, heavier workloads and sicker clients
A nurse is caring for a client who refuses to take the prescribed medication, stating that she is allergic to it. What should the nurse do when the client refuses to take the medication? Select all that apply. Inform the nurse manager about the situation. Identify the reason for not administering. Circle the scheduled time on the MAR. Discuss the reason for refusal with the client. Report the situation to the prescriber.
identify the reason for not administering, circle the scheduled time on the MAR, report the situation to the prescriber
A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside the bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting into the bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? identifying risks and ensuring future safety for clients gauging the nurse's professional performance over time protecting the nurse and the hospital from litigation following up the incident with other members of the care team
identifying risks and ensuring future safety for clients
Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation? It documents assessments on separate forms. It records progress under problems, intervention, and evaluation. It provides and refers to a client's problem by a number. It provides quick access to abnormal findings.
it provides quick access to abnormal findings
Which of the following sites results in measuring a client's core body temperature? Rectal Axillary Oral Tympanic
rectal
The nurse is using the nursing process to care for a client and is in the process of making a nursing diagnosis for the client. Which of the following best reflects a nursing diagnosis? Pnuemonia Hypertension Congestive heart failure Risk for falls
risk for falls
The nurse is teaching the parents of an infant with an irregular heartbeat how to check the pulse rate. The infant's pulse is very high and irregular. What will the nurse have to do in order to teach these parents how to monitor their infant's pulse rate? The parents should be encouraged to get a neighbor or family member to help them check their infant's pulse. This infant will need a home cardiac monitor set up. The parents will not be able to check the pulse accurately, the nurse will need to have home health check on this infant on a periodic basis. The parents will have to be taught how to use a stethoscope so that they can listen to and count the infant's apical pulse.
the parents will have to be taught how to use a stethoscope so that they can listen to and count the infant's apical pulse
Which client's blood pressure best describes the condition called hypotension? The systolic reading is below 100 and diastolic reading is below 60. The systolic reading is below 120 and the diastolic reading is below 80. The systolic reading is above 110 and diastolic reading is above 80. The systolic reading is above 102 and diastolic reading is above 60.
the systolic reading is below 100 and diastolic reading is below 60
Bradypnea is a response to IICP. This is a normal respiratory rate. IICP most commonly results in tachypnea. Bradypnea is uncommon in a client with IICP.
there is an ausculatory gap
The nurse is teaching a newly diagnosed hypertensive client how to take his or her own BP at home. The client asks why it is so important to do this. What is the nurse's best response? "Your BP measurements at home are more accurate than the ones we do in the health care setting." "Monitoring your BP at home will assist in controlling your BP, thereby decreasing your risk for heart attack and stroke." "You must do this because the doctor ordered it." "Because it is required by your insurance."
"Monitoring your BP at home will assist in controlling your BP, thereby decreasing your risk for heart attack and stroke."
The nurse takes care of a 49-year-old client who was admitted for acute pancreatitis. The client was admitted yesterday and has been on IV fluids, has been kept NPO (nothing by mouth), and has been given IV pain medications since. During your nursing assessment the client reports pain is a 4
10 on the pain scale. The pain starts in the epigastric area and radiates to the back. The client also has been nauseous this morning. The facility charts by exception. The nurse finishes filling out the flow sheet and has to write a progress note. Which progress note represents charting by exception for this client? Forty-nine-year-old man, 125 mL/h of normal saline, NPO, pain 4/10 on pain scale with 2 mg IV dilaudid every 4 hours 4/10 pain on pain scale, epigastric radiating to back; also complains of nausea NPO, 4/10 pain, epigastric radiating to back, nausea 4/10 pain located in epigastric area and radiating to back with nausea; on IV fluids/ 4/10 pain on pain scale, epigastric radiating to back; also complains of nausea
the nurse is preparing to administer insulin to an older client who is frail and has failure to thrive. At what angle will the nurse plan to insert the needle into the client?At what angle will the nurse plan to insert the needle into the client? 10-15 degrees 20-30 degrees 45 degrees 90 degrees
45 degrees
A 62-year-old female client being treated for hypertension did not take her daily BP medication over the weekend because she was out of medication and the pharmacy was closed. Her average home blood pressure monitoring (HBPM) reading has been 130
82. Today her BP has been 138/90, 135/85, and 142/86. She calls the on-call nurse for her health care provider. What is the most appropriate thing for this nurse to advise this client? Not to worry and to take double the dose of BP medication To take the medication that she missed and retake her BP To call her health care provider To take the recommended daily dose of medication and call the health care provider if the average of her HBPM readings increase/decrease by 10, or if she has any other concerns./ To take the recommended daily dose of medication and call the health care provider if the average of her HBPM readings increase/decrease by 10, or if she has any other concerns
The nurse is preparing to administer insulin to an obese client. At what angle will the nurse plan to insert the needle into the client? 10-15 degrees 20-30 degrees 45 degrees 90 degrees
90 degrees
The nurse is describing the role of the nurse entrepreneur. Which of the following statements best describe this role? A nurse who teaches in a clinical setting A nurse who manages personnel involved in client care A nurse who manages a health-related business A nurse responsible for adminstration of resources
A nurse who manages a health-related business
After hearing a presentation about the American Nurses Association (ANA), a nurse decides to join the organization based on the understanding that: ANA invites students showing excellence in scholarship to become members. ANA aims at fostering high standards of nursing in the United States. Members include nurses, other health care providers, and lay people. membership is open to all nurses in the United States.
ANA aims at fostering high standard of nursing in the US
Which is an appropriately stated nursing intervention? Ambulate 30 ft. twice a day with assistance of a walker. Stand at bedside with assistance. Ambulate with assistance of a walker. Ambulate in the hall.
Ambulate 30 ft twice a day with assistance of a walker
A nursing student has established a strong therapeutic rapport with a patient who was admitted to the hospital with a perforated appendix. The patient is similar in age to the student and is interested in a career in nursing. Before being discharged, the patient asks if she can add the student as a contact on a social networking site in order to ask her more questions about nursing. How should the student respond to the patient's request? Explain why she cannot fulfill the patient's request but offer to meet her in person to answer questions about nursing school. Explain why nursing ethics does not allow online contact between nurses and patients. Explain that nurses are not permitted to have social contact with patients but offer to answer questions before the patient is discharged. Offer to answer the patient's questions by e-mail rather than through contact on a social networking site.
Explain that nurses are not permitted to have social contact with patients but offer to answer questions before the patient is discharged.
A person's core body temperature is highest in the early morning and lowest in the late afternoon. False True
False
What was one barrier to the development of the nursing profession in the United States after the Civil War? Lack of influence from nursing leaders Lack of educational standards Hospital-based schools of nursing Independence of nursing orders
Lack of educational standards
The nurses at a health care facility were informed of the change to organize the clients' records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records? Problem-oriented recording gives the clients the right to withhold the release of their information to anyone. Problem-oriented recording is difficult to demonstrate a unified approach for resolving the clients' problem among caregivers. Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. Problem-oriented recording has numerous locations for information where each member of the multidisciplinary team makes entry about their own specific activities in relation to the client's care.
Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.
The nurse manager is reviewing medication order protocols with staff nurses. Which teaching will the nurse include? (Select all that apply.) Refrain from using abbreviations. Be mindful of look-alike and sound-alike drugs. IU and U are acceptable abbreviations to use. Orders can be carried out without provider signatures. Nurses and healthcare providers are accountable for drug safety.
Refrain from using abbreviations. Be mindful of look-alike and sound-alike drugs. Nurses and healthcare providers are accountable for drug safety.
When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nurse implementing? FOCUS charting SOAP charting PIE charting Narrative charting
SOAP charting
A nursing instructor is discussing differences between nurse-client relationships and social relationships with a group of nursing students. Which statement is a characteristic of a person-centered or helping relationship? A person-centered or helping relationship is characterized by an unequal sharing of information. A person-centered or helping relationship occurs spontaneously with random individuals. A person-centered or helping relationship is built on the needs of the helping person. The person being helped in the person-centered or helping relationship is accountable for the outcomes of the relationship.
a person-centered relationship is characterized by an unequal sharing of information
Carl Rogers (1961) studied the process of therapeutic communication. Through his research, the elements of a "helpful" person were described. They include all of the following except which choice? Empathy Positive regard Analysis Comfortable sense of self
analysis
A nursing student is beginning a shift by taking a patient's vital signs. The student attempts to assess the patient's pulse at the radial site but is unable to locate this pulse. How should the nurse proceed with assessment? Assess the patient's pulse at either the dorsalis pedis or posterior tibial site. Assess the patient's apical pulse using a stethoscope. Promptly inform the patient's physician of this finding. Use an automated vital signs machine to measure the patient's heart rate.
assess the patient's apical pulse using a stethoscope
Which of the following statements accurately decribes the formulation of a nursing diagnosis? Although the registered nurse assigns the nursing diagnosis, the patient care is ultimately the responsiblity of the physician. A member of the healthcare team evaluates the patient and identifies an approved nursing diagnosis. Collection of assessment data provides the basis for identifying nursing diagnoses A nursing diagnosis is first assigned by the physician and modified for the patient by the RN. Nursing care is directed by the nursing diagnosis but there are no legal ramifications for the RN providing care.
collection of assessment data provides the basis for identifying nursing diagnoses
A nurse is responsible for changing the dressing on a patient's infected wound, a procedure that has caused the patient significant pain in the past. Which of the nurse's actions best demonstrates an understanding of the pharmacokinetics of the pain medication that the nurse will administer? Considering the patient's preferences for analgesia Administering the lowest possible dose of the medication in order to achieve a therapeutic effect Knowing the onset of the medication when deciding when to administer it Giving small, repeated doses of the medication rather than one larger dose
knowing the onset of the medication when deciding when to administer it
Besides being an instrument of continuous client care, the client's health care record also serves as a(an): assessment tool. legal document. Kardex. incident report.
legal document
A nurse can most accurately assess a client's heart rate and rhythm by which of the following methods? Listen with the stethoscope at the fifth intercostal space at the sternum. Listen with a stethoscope at the second intercostal space left sternum. Listen with a stethoscope at the neck to the right of the coracoid process. Listen with the stethoscope at the fifth intercostal space left mid-clavicular line.
listen with the stethoscope at the 5th intercostal space left mid-clavicular line
While assessing vital signs of a client with a head injury and increased intracranial pressure (IICP), a nurse notes that the client's respiratory rate is 8 breaths
minute. How will the nurse interpret this finding? bradypnea is a response to IICP
A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure? Over the client's thigh Radial artery Brachial artery Over the lower arm
over the client's thigh
The nurse is preparing to apply nitroglycerin paste. After checking the order, washing hands, checking the client's identity, and applying gloves, which is the next nursing action? removing prior application and any remaining residue from skin covering application paper with plastic with transparent semipermeable dressing squeezing prescribed amount of paste from tube onto application paper using wooden applicator to spread paste over the paper
removing prior application and any remaining residue from skin
What is the best nursing intervention to promote health in a client at risk for heart disease? Emphasizing a client's strengths to encourage weight loss Instructing client to adhere to a high-sodium diet Taking the client's pulse rate daily Informing the client that he
she must lose weight/ emphasizing a client's strengths to encourage weight loss
A client that has been taught to monitor her pulse calls the nurse because she is having difficulty feeling it strongly enough to count. She states that she takes her pulse before taking her cardiac medication. She sits down with her nondominant arm on a firm service, palm up. She uses her three fingers to feel just below the wrist on the side closest to the body. She does not press hard and she has a watch with a second hand to use to count it, but she has a very difficult time feeling it. What does the nurse recognize that she is doing wrong? She needs to take her pulse after her medication so that her pulse is stronger. She needs to press harder until she feels a pulse. She should stand when taking her pulse to increase blood flow. She should place her three fingers just below the wrist on the outside of the arm with the palm up.
she should place her three fingers just below the wrist on the outside of the arm with the palm up
A nurse is attempting to communicate with a client who speaks a different language and does not understand what is being communicated. Which nursing action would best facilitate the communication process? speaking slowly and distinctly, but not loudly repeating the message in the same manner many times until understood using medical terms and abbreviations more frequently avoiding using a dictionary to help maintain focus on the client
speaking slowly and distinctly, but not loudly
A nurse is administering enoxaparin sodium (anticoagulant) to a client with deep vein thrombosis, via the subcutaneous route. What is a recommended guideline when administering a subcutaneous injection? Sites commonly used for a subcutaneous injection are the inner surface of the forearm and the upper back, under the scapula. Subcutaneous injections are administered into the adipose tissue layer just below the epidermis and dermis. Subcutaneous injections are administered at a 30- to 45-degree angle based on the amount of subcutaneous tissue present. Pinching is advised for obese clients to lift the adipose tissue away from underlying muscle and tissue.
subcutaneous injections are administered into the adipose layer just below the epidermis and dermis
An 80-year-old client has a body temperature of 97°F (36°C). Which condition best accounts for this client's temperature reading? Temperature drops with age. Hypothyroidism The client is anemic. Altered endocrine function
temperature drops with age
Which explanation differentiates the Registered Nurse (RN) from the Licensed Practical Nurse (LPN)? The LPN can only work in a long-term facility. The RN is permitted to prescribed medications. The LPN should work under the supervision of an RN. The RN directs the workload of an LPN.
the LPN works under the supervision of a RN
The definition of implementation would include which of the following? The action phase of the nursing process in which nursing care is provided. The development of outcome criteria. The proper documentation of the nursing assessment The inclusion of the patient in establishing outcome goals. The use of assessment skills to develop a nursing diagnosis.
the action phase of the nursing process in which nursing care is provided
A nurse is providing care for clients in a long-term care facility. Based on the definitions of nursing in the textbook, what should be the central focus of this care? the client receiving the care the nurse as the caregiver the nursing actions provided by the nurse nursing as a profession
the client receiving care
When administering beta blocker medications, the physician adds an order to hold medication when the client is bradycardic. Which statement explains this order? The client's systolic blood pressure is less than 100 mm Hg. The client's pulse rate is below 60 beats per minute. The client's respiratory rate is less than 18 breaths per minute. The client is unable to stay upright when blood pressure is checked.
the client's pulse is below 60 bpm
Pulse deficit can provide the nurse information regarding the heart's ability to profuse blood to the systems. Which statements describe pulse deficit? Select all that apply. the total volume of blood during ventricular contraction Report to the health care provider any increase in pulse deficit. the difference between apical and peripheral pulse rate The apical pulse is higher than the radial pulse. the pulse pressure created when there is friction between the blood and the vessel walls
the difference between apical and peripheral pulse rate, the apical pulse is higher than the radial pulse, report to the health care provider any increase in pulse deficit
A nurse is assessing the blood pressure of a client using the Korotkoff sound technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record? There is an auscultatory gap. There is a widening in the diameter of the artery. There is an adult diastolic pressure. There is a nonauscultatory gap.
there is an auscultatory gap
