last exam for foundations

During data collection, the client expresses concern over a change in the color of the urine from tea-colored to green since beginning a new medication. Which appropriate question would the nurse ask this client?

"Are you taking any B-complex vitamins?"

Which statement, if made by an adolescent preparing for abdominal surgery, would indicate to the nurse that the client requires additional instruction?

"I can have a hamburger and French fries as soon as I wake up."

A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy?

"I will receive parenteral vitamin B12 therapy for the rest of my life."

Which statement by the nurse is a culturally appropriate reaction to a client's perception of pain?

"If a client needs to yell in pain, that is his or her right."

Which statement by the nurse demonstrates ethnocentrism?

"That client needs to learn that pain is best managed with traditional medications like morphine."

The nurse is caring for an older adult client suspected of having a urinary tract infection. The nurse should assess for what finding specifically associated with the development of this condition in the older adult?

Acute confusion

A client has been experiencing increasing shortness of breath and fatigue. The health care provider has ordered a diagnostic test in order to determine what type of heart failure the client is having. What diagnostic test does the nurse anticipate being ordered?

An echocardiogram

Which nursing intervention should be incorporated into the plan of care to manage the delayed clotting process in a client with leukemia?

Apply prolonged pressure to needle sites or other sources of external bleeding

Which nursing intervention should be incorporated into the plan of care to manage the delayed clotting process due to thrombocytopenia in a client with leukemia?

Applying prolonged pressure to needle sites or other sources of external bleeding

While assessing an older adult client's upper back, the nurse notes round, raised red spots along the client's back. The client's daughter says, "Oh, that is just cupping." What action should the nurse take?

Ask about the practice of cupping.

A nurse caring for a client who has hemophilia is getting ready to take the client's vital signs. What should the nurse do before taking a blood pressure?

Ask if taking a blood pressure has ever produced bleeding under the skin or in the arm joints.

The nurse is caring for a client of a different culture and strives to deliver culturally sensitive care. Which action by the nurse is most appropriate?

Ask inquisitive questions regarding the client's cultural practices.

A middle-aged adult was rushed to the emergency department after sustaining a broken ankle due to a fall. The client only speaks German and the nurse only speaks English. An interpreter was asked to help. Which action(s) should be implemented?

Ask questions that are answerable by a yes or no. Allow adequate time for the interpreter to translate. Allow a family member to help with the translation.

A client arrives at the ED with an exacerbation of left-sided heart failure and reports shortness of breath. Which is the priority nursing action?

Assess oxygen saturation

The nurse is caring for a client in the postanesthesia care unit (PACU). Which assessment is the priority for this client?

Assess respiratory status.

A nurse is planning interventions for a client to assist in establishing a normal voiding pattern. Which nursing action should be included?

Assist the client to a normal voiding position when possible.

The nurse is planning care for a client with severe fatigue secondary to anemia. What concept will the nurse use as the basis for planning interventions?

Assisting in prioritizing activities.

The nurse is caring for a client with type 2 diabetes who take metformin to manage glucose levels. The nurse recognizes the client may be most at risk for which vitamin deficiency?

B12

When teaching a client with iron deficiency anemia about appropriate food choices, the nurse encourages the client to increase the dietary intake of which foods?

Beans, dried fruits, and leafy, green vegetables

A new resident in a long-term care facility who was having difficulty adapting to the routine has begun participating in activities on a daily basis. Which stage of culture shock is this resident displaying?

Beginning resolution

A client with heart failure is having a decrease in cardiac output. What indication does the nurse have that this is occurring?

Blood pressure 80/46 mm Hg

Which is a symptom of hemochromatosis?

Bronzing of the skin

The nursing instructor is teaching their clinical group how to assess a client for congestive heart failure. How would the instructor teach the students to assess a client with congestive heart failure for nocturnal dyspnea?

By questioning how many pillows the client normally uses for sleep

The nurse is preparing to irrigate a Foley catheter. What is the nurse's initial action?

Check electronic health record for medical order.

The nurse is caring for a client in the hospital with chronic heart failure who has marked limitations in his physical activity. The client is comfortable when resting in the bed or chair, but when ambulating in the room or hall, the client becomes short of breath and fatigued easily. What type of heart failure is this considered according to the New York Heart Association (NYHA)?

Class III (Moderate)

A nurse is interacting with a client in the outpatient surgical unit intraoperatively. What is the nurse's priority responsibility?

Client safety

The nurse is instructing a client about taking a liquid iron preparation for the treatment of iron-deficiency anemia. What should the nurse include in the instructions?

Dilute the liquid preparation with another liquid such as juice and drink with a straw.

The nurse is caring for a client with external bleeding. What is the nurse's priority intervention?

Direct pressure

The nurse and the client are discussing some strategies for ingesting iron to combat the client's iron-deficiency anemia. Which is among the nurse's strategies?

Drink liquid iron preparations with a straw.

The diagnosis of heart failure is usually confirmed by which of the following?

Echocardiogram

A nurse is caring for a female client with an indwelling urinary catheter. Which action should the nurse take into consideration to reduce the client's risk of developing a urinary tract infection (UTI)?

Ensure that the catheter is removed as soon as possible.

A client tells the nurse that the only thing that helps the client sleep is a glass of warm milk. The nurse caring for the client insists that this cultural practice is a myth and tries to convince the client that reading a book would be better. What is the nurse demonstrating?

Ethnocentrism

The nurse is performing a preoperative assessment of a client who has been scheduled for a reduction mammoplasty (breast reduction). The client states, "I'm starting to wonder if I made the right decision in going ahead with this." What should the nurse do next?

Explore the client's feelings and inform the surgeon.

Which medication is categorized as a loop diuretic?

Furosemide

The nurse is caring for a client who had an arteriovenous (AV) graft surgically placed. The client is preparing for discharge. Which actions should the nurse teach the client to avoid? Select all that apply.

Having blood pressure measurements in the affected arm. Getting venipuncture in the affected arm. Carrying heavy items including purses or luggage with the affected arm. Sleeping with the affected arm under the head or body

The nurse is preparing to educate a group of students on the signs and symptoms of disseminated intravascular coagulation (DIC). The nurse knows that teaching was effective when the students are able to recognize which symptom as being associated with DIC?

Headache, cyanotic extremities, capillary refill in 6 sec.

A nurse is caring for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. What condition should the nurse suspect?

Heart failure

Which of the following describes a red blood cell (RBC) that has pale or lighter cellular contents?

Hypochromic

Which New York Heart Association classification of heart failure has a poor prognosis and includes symptoms of cardiac insufficiency at rest?

IV

A 9-month-old infant is scheduled for heart surgery. When preparing this client for surgery, the nurse should consider which surgical risk associated with infants?

Impaired thermoregulation

A client with severe anemia reports symptoms of tachycardia, palpitations, exertional dyspnea, cool extremities, and dizziness with ambulation. Laboratory test results reveal low hemoglobin and hematocrit levels. Based on the assessment data, which nursing diagnoses is most appropriate for this client?

Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit

A client is scheduled for hip replacement surgery this morning but admits to the nurse that he had a small piece of toast and some water after waking up. What is the nurse's most appropriate response?

Inform the anesthesiologist or surgeon of this fact.

Which teaching statement best exemplifies cultural competence in relation to time for the American culture?

It is important to be on time for your health care appointment.

The nurse is performing an assessment for a client with anemia admitted to the hospital to have blood transfusions administered. Why would the nurse need to include a nutritional assessment for this patient?

It may indicate deficiencies in essential nutrients.

Which is a characteristic of right-sided heart failure?

Jugular vein distention

The nurse is assessing a client who is unresponsive. To obtain information about the client's culture, the nurse interviews a person who has native knowledge about the client's culture. Which technique is the nurse using?

Key informant

A nurse administers anticholinergics to a client as a postoperative medication. What condition does this medication help to prevent?

Laryngospasm

The nurse cares for a client following surgery to repair an abdominal aortic aneurysm. Which nursing intervention assists with healing and maintaining client comfort?

Maintaining a calm environment

A nurse is caring for a female client who is unable to transfer to a commode. The nurse is assisting the client with positioning on a bedpan. Which statement should guide the nurse's action?

Many clients find it embarrassing or degrading to use a bedpan.

Which action will the nurse include in the plan of care for a client admitted with acute decompensated heart failure (ADHF) who is receiving milrinone?

Monitor blood pressure frequently

A nurse is maintaining a client's continuous bladder irrigation. When appraising the effectiveness of this therapy, the nurse should prioritize what assessment?

Monitoring the characteristics of the urinary output

A nursing instructor is evaluating a student caring for a neutropenic client. The instructor concludes that the nursing student demonstrates accurate knowledge of neutropenia based on which intervention?

Monitoring the client's temperature and reviewing the client's complete blood count (CBC) with differential

A client with a diagnosis of pernicious anemia comes to the clinic reporting of numbness and tingling in his arms and legs. What do these symptoms indicate?

Neurologic involvement

A client states having a latex allergy. Which action does the nurse take to communicate this allergy to hospital staff caring for the client?

Note the allergy on the client's record.

A client with multiple myeloma is complaining of severe pain when the nurse comes in to give a bath and change position. What is the priority intervention by the nurse?

Obtain the pain medication and delay the bath and position change until the medication reaches its peak.

Which describes difficulty breathing when a client is lying flat?

Orthopnea

Which stereotypical ideas about older adult clients does the nurse associate with the concept of ageism? Select all that apply.

Physically impaired Burdensome to family Uninterested in intimacy

While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters?

Platelet count, prothrombin time, and partial thromboplastin time

A nurse is assessing clients in the Post Anesthesia Care Unit (PACU). Which nursing actions would the nurse perform in this phase of the perioperative period? Select all that apply.

Prepare the client for home care. Assess the client's ability to return to the inpatient room when arousable. Assess for complications as the client emerges from anesthesia.

The nurse is assessing an infant of Asian descent and notes dark blue spots on the infant's lower back. What action should the nurse take next?

Press lightly on the pigmented area and observe the infant's reaction.

The nurse is teaching the client who recently experienced abdominal surgery to deep breathe and cough effectively. What observable action serves to best minimize pain that may result from the intervention?

Providing support to abdominal and accessory respiratory muscles

A client has been diagnosed with heart failure. What is the major nursing outcome for the client?

Reduce the workload on the heart.

The nurse recognizes which symptom as a classic sign of cardiogenic shock?

Restlessness and confusion

The nurse completes the task of changing the dressing of a recent surgically inserted peritoneal dialysis catheter. The nurse has applied antibiotic ointment as prescribed, covered the site with 4 × 4 gauze, and labeled the dressing with the date, time of change, and initials of the nurse performing the task. Prior to leaving the client's bedside, the nurse should complete which task next?

Secure the tubing of the peritoneal dialysis catheter to the client's abdomen.

A client is prescribed 325 mg/day of oral ferrous sulfate. What does the nurse include in client teaching?

Take 1 hour before breakfast

The nurse is caring for a client who had a procedure under moderate sedation at the ambulatory surgical center. Which assessment finding indicates to the nurse that the client may be ready for discharge to home?

The client is alert and oriented with a blood pressure 118/70 mm Hg and respirations 18 breaths/minute, is able to ambulate, is not nauseated or vomiting, pain is controlled with medication, and has no excessive bleeding and drainage is as expected.

A client with right-sided heart failure is admitted to the medical-surgical unit. What information obtained from the client may indicate the presence of edema?

The client says his rings have become tight and are difficult to remove.

A female client age 54 years has been scheduled for a bunionectomy (removal of bone tissue from the base of the great toe) which will be conducted on an ambulatory basis. Which characteristic applies to this type of surgery?

The client will be admitted the day of surgery and return home the same day.

A client has a myocardial infarction in the left ventricle and develops crackles bilaterally; 3-pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client?

The development of left-sided heart failure

What is the main difference between Class I and Class II heart failure as defined by the New York Heart Association (NYHA)?

The level of physical activity each allows

The novice nurse is assessing the urinary bladder of a client with transient urinary incontinence. The nurse mentor would intervene if which action by the novice nurse is noted?

The novice nurse asks the client to urinate before palpating the bladder.

The nurse mentor is observing a novice nurse preparing to insert an indwelling catheter for a female client with urinary retention. The mentor would intervene if which action by the novice nurse is noted?

The novice nurse selects an 18 French Foley catheter to insert.

A client reports to the primary health care facility for routine physical examination after cardiac rehabilitation following myocardial infarction. How should the nurse conduct the interview?

The nurse should avoid using medical terminology.

A patient is taking prednisone 60 mg per day for the treatment of an acute exacerbation of Crohn's disease. The patient has developed lymphopenia with a lymphocyte count of less than 1,500 mm3. What should the nurse monitor the client for?

The onset of a bacterial infection

The nurse is teaching a client about postoperative pain management. The client states, "I would like to use as little medication as possible after surgery. Will anything else help to relieve my pain?" Which response is appropriate?

There are several nonpharmacologic methods to reduce pain and anxiety. Let me teach you about some of them."

Which statements about suprapubic catheters is true?

They are often preferred over an indwelling urethral catheter for long-term urinary drainage.

After receiving chemotherapy for lung cancer, a client's platelet count falls to 98,000/mm3. What term should the nurse use to describe this low platelet count?

Thrombocytopenia

A nurse is doing a physical examination of a child with sickle cell anemia. When the child asks why the nurse auscultates the lungs and heart, what would be best the response by the nurse?

To detect the abnormal sounds suggestive of acute chest syndrome and heart failure

The nurse should advise a client with iron deficiency anemia to take which action in order to prevent staining of the teeth?

Use a straw or place a spoon at the back of the mouth to take the liquid supplement.

A nurse is inserting a catheter into a female urinary bladder. Which nursing action is performed correctly?

Use dominant hand to inflate the catheter balloon, and inject entire volume of sterile water supplied in prefilled syringe.

A nurse is assigned to care for a client who does not speak the dominant language. An interpreter has been contacted and will be at the bedside shortly. Which action by the nurse would be most effective in reassuring the client until the interpreter arrives?

Using reassuring body language and making eye contact to assess needs

A client is seen in the emergency department with severe pain related to a sickle cell crisis. What does the nurse understand is occurring with this client?

Vascular occlusion in small vessels decreasing blood and oxygen to the tissues.

For a client diagnosed with pernicious anemia, the nurse emphasizes the importance of lifelong administration of

Vitamin B12

The nurse is performing an assessment for a Native American/First Nations client who is hesitant to answer questions related to psychosocial history. What action by the nurse will facilitate communication between the nurse and the client?

Wait to write down notes or put the information in the computer until after the interview, if possible.

A young client is diagnosed with a mild form of hemophilia and is experiencing bleeding in the joints with pain. In preparing the client for discharge, what instructions should the nurse provide?

Wear a medical identification bracelet.

A client with stage IV heart failure has a living will indicating a ventilator may not be used. The client begins experiencing severe dyspnea. What should the nurse who is caring for this client do?

administer oxygen, morphine, and a bronchodilator for client comfort.

A male client is being transferred to the hospital from a long-term care facility with a diagnosis of dehydration and urinary bladder infection. The client's skin is also excoriated from urinary incontinence. Which nursing concern is most appropriate for the nurse to include in this client's car plan?

altered skin integrity related to urinary bladder infection and dehydration

A client has been diagnosed with congestive heart failure. This client's cardiac function has been compromised since the client suffered a myocardial infarction 3 years ago. Heart failure is classified by:

amount of activity restriction the failure imposes.

Surgery can lead to hypothermia. Which client is at greatest risk for hypothermia?

an older adult man with a fractured hip

The client is a new client in the outpatient wellness clinic. The client reports frequent urinary incontinence of recent onset. The nurse reviews the client's list of medications. Which medication classification will the nurse review with the client to determine when the prescription was started?

antihypertensive

Ethnocentrism

belief in the superiority of one's own ethnic group

The most common cause of iron deficiency anemia in men and postmenopausal women is

bleeding

When collecting a urine sample from a client for examination, the nurse notes that the sample appears reddish-brown in color. What could cause this variation in color of the urine?

blood

During his stay in the hospital, a male client has established a pattern of maintaining urinary continence during the day, but he is experiencing incontinence at night. What intervention should the nurse implement in this client's care?

condom catheter

A parent informs the nurse that immunizations are against the parent's cultural and religious beliefs and the parent does not want the child to receive immunizations. The nurse proceeds to inform the parent that the child will be consistently ill and will not be allowed to start school unless immunized. The nurse also informs the parent that the nurse had all of the nurse's own children vaccinated. The nurse's behavior an example of:

cultural imposition.

Healthcare facilities that sponsor health promotion activities only in affluent areas are considered:

culturally blind.

A nurse is caring for a 79-year-old client who is new to a long-term care facility. Previously, the client lived in a rural community in a household consisting of the client and an adult child. The child is no longer able to care for the client. The client appears disoriented and reports being bothered by the "bright lights and constant activity." The nurse appropriately documents what condition in the chart?

culture shock

A nurse caring for a client recently admitted to the ICU observes the client coughing up large amounts of pink, frothy sputum. Lung auscultation reveals coarse crackles in the lower lobes bilaterally. Based on this assessment, the nurse recognizes this client is developing

decompensated heart failure with pulmonary edema.

The nurse is inserting a urinary catheter into a female client and has begun to inflate the balloon, an action that has caused the client to wince and cry out in pain. Consequently, the nurse should:

deflate the balloon, insert the catheter further, and slowly attempt reinflation.

A client reports that he is often unable to retain urine until he locates a toilet because his mobility is decreased. The nurse should recognize the characteristics of what type of incontinence?

functional

The nurse is teaching a client about medications prescribed for severe volume overload from heart failure. What diuretic is the first-line treatment for clients diagnosed with heart failure?

furosemide

The nurse is caring for a client with advanced heart failure. What treatment will be considered after all other therapies have failed?

heart transplant

The nurse is assessing a client with crackling breath sounds or pulmonary congestion. What is the cause of the congestion?

inadequate cardiac output

pernicious anemia

lack of mature erythrocytes caused by inability to absorb vitamin B12 into the bloodstream

Which factors contribute to the concept of a culture? Select all that apply.

language, items and clothing worn, types of disease contracted, beliefs about health practices, styles use for communication

Which assessment data, collected by the nurse, indicates that a client may be assigned the nursing concern of urge urinary incontinence? Select all that apply.

loses urine when a toilet is not readily available urinates 20 times in 24 hours experiences accidental loss of urine when there is an urgent need to urinate

An operating room nurse is bringing a client to the nurse in the postanesthesia care unit (PACU). Which information would the operating room nurse provide during a hand-off report? Select all that apply.

medications given in operating room. length of surgery. drains inserted in surgery

A client is prescribed digitalis medication. Which condition should the nurse closely monitor when caring for the client?

nausea and vomiting

The nurse completes an assessment of a client admitted with a diagnosis of right-sided heart failure. What will be a significant clinical finding related to right-sided heart failure?

pitting edema

The nurse recognizes the value of leg exercises in the prevention of postoperative thrombophlebitis. When should the nurse teach the correct technique for leg exercises to a client?

prior to surgery

A client has recently immigrated to the country and is exhibiting symptoms of culture shock. The client reports feeling unaccepted in the new culture. The client states, "I cannot do anything correct here." What is the priority nursing concern for care planning?

situational low self-esteem related to culture shock and feelings of fear and incompetence

The nurse is admitting a new client who is a member of the Navajo Nation. Which action should the nurse consider while conducting the interview?

write notes after the interview