NRSG 1500 Final (EAQ Remediation Questions)

A 92 year old male lives in extended care facility. After suffering a stroke last year, he has been immobile with right sided weakness. For the third day in a row, the nursing assistant states that he has not had a bowel movement although today he has been having liquid diarrhea. The nurses priority action is to: a. Call the provider to obtain an order for an enema b. Assess the patient for an impaction c. Assess the patient for an ileus d. Increase the fiber and fluids in the patient's diet

B. Assess the patient for an impaction

In which way is public health nursing different from community health nursing? a. Public health nursing focuses on a population b. Public health nursing focuses on health promotion c. Public health nursing is part of a primary health care delivery system d. Public health nursing requires nurses to hold a graduate degree

A. Public health nursing focuses on a population

Which intervention is most important in preventing hospital acquired catheter associated urinary tract infections (CAUTIs)? a. Removing the catheter b. Keeping the drainage bag off of the floor c. Washing hands before and after assessing the catheter d. Cleansing the urinary meatus with soap and water daily

A. Removing the catheter

Which feature is associated with the "maturation phase" of normal wound healing? a. The scar is firm and inelastic on palpation b. Fibrin strands form a scaffold or framework c. White blood cells migrate into the wound d. Epithelial cells are grown over the granulation tissue bed

A. The scar is firm and inelastic on palpation

The nurse places a school-aged child with bacterial meningitis in isolation with droplet precautions. Which is the purpose of these precautions? a. They keep the child away from uninfected people. b. The infectious process is interrupted as quickly as possible c. The child is protected from contracting a secondary infection d. They prevent the development of a hospital-acquired infection

A. They keep the child away from uninfected people.

The nurse providing care for a client, whose forehead feels warm to the touch, uses a thermometer to obtain the clients temperature. Which action is the nurse taking? a. Validation b. Assessment c. Interpretation d. Documentation

A. Validation

When a client reports a sudden onset of chest pain that feels like a pressure or weight on her chest which action would the nurse take first? a. Call the rapid response team b. Check blood pressure and heart rate c. Administer the prescribed as-needed nitroglycerin 0.4mg d. Ask whether there have been previous episodes of similar pain

B. Check blood pressure and heart rate

Which situation would the nurse address first according to Maslow's hierarchy? a. Has history of being injured from sudden falls b. Complains of sleeplessness due to pain post surgery c. Reports that they feel lonely and socially isolated d. Conveys to the nurse that they want to become the manager of the company

B. Complains of sleeplessness due to pain post surgery

Which explanation with the nurse include when teaching a client with heart failure about the reason for a low sodium diet? a. Body weight control b. Decreased fluid retention c. Lowering of blood pressure d. Prevention of hypernatremia

B. Decreased fluid retention

A nurse is caring for a 51 year old patient who has vomiting and diarrhea for the past five days. Which expected physiological change is most concerning for the nurse? a. Increased afterload b. Decreased preload c. Increased stroke volume d. Decreased energy levels

B. Decreased preload

A nurse is caring for an 86-year-old female patient with chronic renal failure and assess his recent lab work. The nurse notes a hemoglobin of 8.2 and hematocrit of 27.4. The nurse is aware that the likely explanation for the anemia relates to: a. The lack of central perfusion to the kidneys b. Decreased production of erythropoietin c. Recent blood loss through the gastrointestinal system d. Hemodilution from excess fluids

B. Decreased production of erythropoietin

While providing care for an obese client who underwent an open cholecystectomy, the nurse identifies a separation in the surgical incision. Which complication is the client experiencing? a. Adhesions b. Dehiscence c. Evisceration d. Contractions

B. Dehiscence

The nurse, speaking in support of the best interest of a vulnerable client reflects which nursing duty? a. Caring b. Veracity c. Advocacy d. Confidentiality

C. Advocacy

The nursing student assesses a client with abdominal pain. Which action performed by the nursing student needs correction? a. Assessing the factors that worsen the pain b. Asking the client about sleeping patterns c. Assessing the client for tenderness and dimpling d. Asking the client about the time and type of pain

C. Assessing the client for tenderness and dimpling

Which action would the nurse take when caring for a client with a deep soft tissue injury that is open and oozing blood? a. Replace the dressing when it is completely saturated b. Leave the dressing until the primary health care provider makes rounds c. Change the dressing each time the blood oozes through the outside layer d. Automatically pack the wound with anti microbial gauze each time the dressing is changed

C. Change the dressing each time the blood oozes through the outside layer

Which nursing action is most appropriate to help reduce the likelihood of an older adult client falling during the night? a. Moving the client's bedside table closer to the bed b. Encouraging the client to take an available sedative c. Instructing the client to call the nurse before going to the bathroom d. Assisting the client to telephone home to say goodnight to the spouse

C. Instructing the client to call the nurse before going to the bathroom

Which assessment finding will the nurse report to the healthcare provider when caring for a patient immediately following placement of an ostomy? a. Moderate edema of the stoma b. Excessive gas in the pouch c. Pale, moist stoma d. Small amount of stool oozing from the stoma

C. Pale, moist stoma

Which action would the nurse take first when caring for a postoperative client who reports pain? a. Provide an ice bag b. Administer pain medication as prescribed c. Perform a focused assessment of the client d. Document the client's complaint in the chart

C. Perform a focused assessment of the client

Which statement describes the steps, followed to provide competent care for vulnerable populations? a. "Refrain from giving priority to cultural practices and values of the vulnerable populations." b. "Provide financial in legal advice to the vulnerable people, as this may be more important to them." c. "Evaluate the clients beliefs and values about health in terms of the nurses own culture, beliefs and values." d. "Understand the clients' cultural beliefs, values, and practices to determine their specific needs an intervention."

D. "Understand the clients' cultural beliefs, values, and practices to determine their specific needs an intervention."

Which recommendation with the nurse make to a parent to address bedtime resistance in a four-year-old child? a. "You should sleep with your child" b. "You should listen to your child's concerns" c. "You should implement consequences for your child" d. "You should limit screen time in the hour before bedtime'

D. "You should limit screen time in the hour before bedtime

Which type of health service would the nurse offer in a health promotion or primary care program? a. Home care b. Immunization c. Sports medicine d. Nutrition counseling

D. Nutrition counseling

During which step of the nursing process would the nurse prioritize nursing diagnoses? a. Planning b. Analysis c. Evaluation d. Assessment

A. Planning

When a client with a heart murmur reports gaining weight in spite of nausea and anorexia, which additional information would be a priority for the nurse to obtain? a. Presence of a cough and exertional dyspnea b. Dietary food and salt intake in the past 24 hours c. Changes in voiding and bowel patterns within the past month d. History of childhood streptococcal infection or rheumatic fever

A. Presence of a cough and exertional dyspnea

Which question asked by the nurse is most appropriate to assess the nature of a clients pain? a. "Can you describe your pain to me?" b. "Is your pain associated with movement?" c. "Can you rate your pain on a scale of 0 to 10?" d. "Do you notice your pain worsening with any activity?"

A. "Can you describe your pain to me?"

Which assessment with the nurse perform first for a client with severe trauma? a. Airway b. Disability c. Breathing d. Circulation

A. Airway

Which sleep promotion technique would the nurse advise during a routine clinic visit when an older adult complains about being unable to sleep well at night and then feeling sleepy throughout the next day? a. Include age-appropriate exercise daily b. Read in bed before sleeping c. Avoid naps during the daytime d. Have a hot cup of tea at bedtime

A. Include age-appropriate exercise daily

Which combination of client responses would the nurse determine represents the highest risk for the development of pressure injuries? a. Incontinence; inability to move independently b. Periodic diaphoresis; occasional sliding down in bed c. Minimal reaction to painful stimuli; receiving tube feedings d. Spending extensive time in a chair; body mass index of 23

A. Incontinence; inability to move independently

Which purpose does a community health center serve and preventative and primary care services? a. Outpatient clinics that provide primary care to a specific population b. Aim to increase worker productivity, decreased absenteeism, and reduce the use of costly medical care. c. Emphasize program management, interdisciplinary, collaboration, and community health principles. d. Include a complete program designed for health promotion and accident or illness prevention in the workplace.

A. Outpatient clinics that provide primary care to a specific population

Which safety measure with the nurse instruct a parent of a toddler to follow? a. Place window guards on all windows b. Have the toddler sleep on the back or side c. Start swimming training for the toddler under supervision d. Teach the child how to cross streets and walk in parking lots

A. Place window guards on all windows

The nurse is caring for a two day post surgery hip replacement. Client who has had a bowel movement, which nursing intervention with the nurse perform next. a. Provide perineal care. b. Turn and position the client. c. Give a complete bed bath. d. Document the bowel movement.

A. Provide perineal care.

Which nursing intervention helps prevent complications associated with the shorten urethra revealed by a recent intravenous pyelogram? a. Providing thorough perineal care after each voiding b. Encouraging the client to use the toilet or bedpan every 2 hours c. Responding quickly to the client's indication of the need to void d. Applying voiding stimulants to the perineum

A. Providing thorough perineal care after each voiding

Which color would the nurse anticipate when assessing a client skin tears? a. Red b. Gray c. Black d. Yellow

A. Red

Which recommendation would the nurse make to a parent who is concerned their preschooler often awakens screaming in the middle of the night and is not easily comforted? a. "Always read a story to the child before bedtime" b. "Intervene only if necessary to protect the child from injury" c. "Discuss counseling options with the primary health care provider' d. "Try to wake the child and ask the child to describe the dream"

B. "Intervene only if necessary to protect the child from injury"

Which recommendation would the nurse provide the parent of a 14-month-old child about bowe training? a. "Place the child on the toilet every 2 hours." b. "Start by purchasing a potty chair." c. "Avoid bowel training until the child is 2 years old." d. "Begin before the child's diet consists mainly of solid foods."

B. "Start by purchasing a potty chair."

The nurse is providing care to a client who is receiving enteral feedings via a nasogastric (NG) tube, which series complication would the nurse take measures to prevent? a. Skin breakdown b. Aspiration pneumonia c. Retention ileus d. Profuse diarrhea

B. Aspiration pneumonia

A patient is receiving opioids for pain after a bowel resection two days ago. Which bowel assessment is a priority? a. Check stool for occult blood b. Assess bowel sounds c. Assess for hemorrhoids d. Monitor for incontinence of liquid stools

B. Assess bowel sounds

The nurse is explaining the nursing process to a student nurse. Which step of the nursing process would include interpretation of data collected about the client? a. Evaluation b. Assessment c. Implementation d. Diagnosis

B. Assessment

Which nursing intervention with the nurse implement for a client with active tuberculosis he was walking down the hall to obtain a glass of juice from the kitchen, even after having received education regarding airborne precautions? a. Ensure regular visits by staff members to meet the client needs. b. Explore what the airborne precautions mean to the client. c. Report the situation to the infection control nurse immediately. d. Reteach the concepts of airborne precautions to the client.

B. Explore what the airborne precautions mean to the client

Which action reflects a primary task in the analysis step of the nursing process? a. Initiating nursing actions b. Forming diagnostic conclusions c. Identifying realistic patient goals d. Examining the effectiveness of interventions

B. Forming diagnostic conclusions

Which client situation will the nurse address first on priority basis of Maslow's hierarchy of needs? a. Feels like they are leading a worthless life b. Has multiple fainting episodes due to lack of proper nutrition c. Shows signs of lack of interest in carrying out social interaction d. Conveys to the nurse that is estranged from all family members

B. Has multiple fainting episodes due to lack of proper nutrition

Which statement indicates that the nurse is an advanced beginner stage of Benner? a. Learns about the profession through a specific set of rules and procedures. b. Identifies the basic principles of nursing care through careful observation. c. Understands the organization in specific care required by certain clients. d. Assesses the entire situation and transfers knowledge gained from multiple previous experiences.

B. Identifies the basic principles of nursing care through careful observation.

Which example indicates the nurse is following the objectives of an evidence based practice? a. Documents client care in an electronic health record b. Reads current nursing journals and uses the latest scientific methods c. Uses flowcharts and diagrams to record the client's progress d. Encourages the hospitalized client's family to bring home cooked food

B. Reads current nursing journals and uses the latest scientific methods

Which initial action would the nurse take when a client reports smoke coming from a utility room on the nursing unit? a. Pull the fire alarm on the unit b. Remove anyone who is in immediate danger c. Obtain a fire extinguisher and report to the fire area d. Close all windows and fire doors and await further instructions

B. Remove anyone who is in immediate danger

In which position with the nurse placed an infant, while the infant is receiving intermittent nasogastric tube feedings? a. Prone b. Semi-Fowler c. Left side-lying d. Supine with the head turned

B. Semi-Fowler

Which definition is correct to explain the nursing process? a. Procedures used to implement client care b. Sequence of steps used to meet the client's needs c. Activities employed to identify a client's problem d. Mechanisms applied to determine nursing goals for the client

B. Sequence of steps used to meet the client's needs

Which conclusion would the nurse make regarding the clients response to pain medication when a client using a pain scale of 1 to 10 rates the pain as an 8 before receiving an analgesic and a 7 after being medicated? a. The client has a low pain tolerance b. The medication is not adequately effective c. The medication has sufficiently decreased the pain level d. The client needs more education about the use of the pain scale

B. The medication is not adequately effective

Which aspect with the nurse consider as a component of the evaluation step of the nursing process? a. The patient is being discharged from the hospital b. The patient's achievement of short and long term goals c. Nurse's completion of interventions in the plan of care d. Nurse's view on the patient's desire to perform interventions

B. The patient's achievement of short and long term goals

Which goal is the main focus of community health nursing? a. To meet the acute care needs of a population b. To improve the quality of health in a population c. To influence political processes affecting public policies d. To assess the health care needs of an individual or family

B. To improve the quality of health in a population

A patient is placed on a therapeutic diet after abdominal surgery. Which food item choice by the patient will the nurse acknowledge as correct understanding of a full liquid diet? a. Steamed vegetables b. Vanilla custard c. Pasta with sauce d. Mashed potatoes and beef gravy

B. Vanilla custard

A client is admitted to the hospital for a laparoscopic cholecystectomy. Which item would the nurse encourage the client to add to the diet to help normalize bowel function after surgery? a. Vitamins b. Whole bran c. Cod liver oil d. Amino acids

B. Whole bran

A nurse is providing teaching to new parents who are asking when they can start potty training their baby. The nurses best response is: a. "You can start taking them to the potty any time after one year of age" b. "They will let you know when they are ready, there is no set time to start" c. "Children can gain bowel and bladder control around 18-24 months" d. "Children can gain bowel and bladder control around 36-48 months"

C. "Children can gain bowel and bladder control around 18-24 months"

Which statement made by an older adult most strongly supports the nurse's conclusion that the client has impacted stool? a. "I have a lot of gas pain." b. "I don't have much of an appetite." c. "I feel like I have to go, but I just seep." d. "I haven't had a bowel movement for several days."

C. "I feel like I have to go, but I just seep."

Which nursing scale is essential to utilize throughout the nursing process? a. Analysis b. Observation c. Critical thinking d. Time management

C. Critical thinking

Which action would the nurse take to prevent aspiration reoccurrence, in a client with aspiration pneumonia who is NPO status with a nasogastric tube and a prescription for antibiotics? a. Obtaining vital signs after feedings b. Administering intravenous antibiotics c. Elevating the head of the bed to 30 degrees d. Determining residual every 4 hours

C. Elevating the head of the bed to 30 degrees

Which step of the nursing process considers the effectiveness of the nursing care? a. Planning b. Analysis c. Evaluation d. Implementation

C. Evaluation

Which objective with the nurse understand about the secondary level of prevention? a. I'm not helping clients achieve the highest function possible b. Focused on minimizing effects of long-term disease or disability c. Focused on individuals who are in the early stage of their illness d. Aimed at attaining health for motion through wellness development activities

C. Focused on individuals who are in the early stage of their illness

Which with the nurse teach the parents of an infant about the use of car seats? a. Infants should ride in a front-facing car safety seat b. Infants should ride in a car safety seat until 1 year of age c. Infants should be restrained properly in a federally approved car safety seat d. Infants should always ride in a car restrained to the front seat of the car

C. Infants should be restrained properly in a federally approved car safety seat

The nurse's physical assessment of a client with heart failure, tachypnea, and bilateral crackles. Which is the priority nursing intervention? a. Obtain chest X-ray film immediately b. Notify the primary health care provider c. Place the client in a high-Fowler position d. Assess the client's oxygen saturation level

C. Place the client in a high-Fowler position

Which factor in the clients history increases the risk for osteoporosis? a. Estrogen therapy b. Hypoparathyroidism c. Prolonged immobility d. Excessive calcium intake

C. Prolonged immobility

The nurse instruct the client to breathe deeply to open, collapsed alveoli. Which explanation could the nurse offer to explain the relationship between alveoli and improved oxygenation? a. The alveoli need oxygen to live b. The alveoli have no direct effect on oxygenation c. Collapsed alveoli increase oxygen demand d. Oxygen is exchanged for carbon dioxide in the alveolar member

D. Oxygen is exchanged for carbon dioxide in the alveolar member

Which scenario explained by the registered nurse teaching about factors that influence sleep is an example of a lifestyle factor? a. "A client reports trouble falling asleep, because of thinking about stress at work." b. "A client in the intensive care unit has not slept properly because of noises and disturbances." c. "A client who has been taking antidepressants, reports, drowsiness and lack of sleep." d. "A client who works rotating overnight shifts reports, fatigue, and difficulty sleeping throughout the night."

D. "A client who works rotating overnight shifts reports, fatigue, and difficulty sleeping throughout the night."

A client is placed on a restricted diet. Which communication is best for the nurse to use when beginning to teach the client about the diet? a. Asking about what type of foods the client usually eats b. Telling the client that the diet must be followed exactly as written c. Telling the client that the intake of foods on the list must be limited d. Asking what the client knows about the diet that was prescribed

D. Asking what the client knows about the diet that was prescribed

Which action would the nurse take after observing dehiscence of the client's abdominal surgical wound with evisceration? a. Obtain vital signs b. Notify the health care provider c. Reinsert the protruding organs using aseptic technique d. Cover the wound with a sterile towel moistened with normal saline

D. Cover the wound with a sterile towel moistened with normal saline

A client with a history of food intolerance experiences, abdominal pain, abdominal distention, and a feeling of fullness. The client is admitted to the hospital for diagnostic testing. Which information is most important for the nurse to obtain when performing the nursing admission history and physical? a. Client's food preferences b. Presence of clay-colored stools c. Amount of splinting by the client d. Detailed characteristics of the pain

D. Detailed characteristics of the pain

Which instruction with the nurse give to the client having a residual urine test? a. Void right after a urinary catheter is removed b. Collect a specimen of urine during midstream c. Attempt to void when a urinary catheter is in place d. Empty the bladder before a urinary catheter is inserted

D. Empty the bladder before a urinary catheter is inserted

Which step of the nursing process involves carrying out nursing actions designed to meet a patient's unique needs? a. Planning b. Analysis c. Evaluation d. Implementation

D. Implementation

The nurse assesses a clients nails and finds a slight convex curve at the angle from the skin to nail base of about 160°. Which condition would the nurse suspect? a. Clubbing b. Paronychia c. Koilonychia d. Normal finding

D. Normal finding

Which statement would the nurse not associate with Orem's theory? a. The theory developed by Orem determines self-care needs b. The Orem theory explains the types of nursing care c. Orem's theory aids in the design of nursing interventions d. The theory describes factors supporting the health of the family

D. The theory describes factors supporting the health of the family

Which stage of pressure ulcer would the nurse document for a client who has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia? a. Stage I b. Stage II c. Stage III d. Unstageable

D. Unstageable

Which action during the admission assessment with the nurse take for an involuntary admitted client who says "I am the second son of God I need to say a prayer"? a. Interrupt the client and continue the assessment b. Join the client in the prayer and then refocus on the assessment c. Quietly leave the client and come back later to complete the assessment d. Wait until the client finishes the prayer and then complete the assessment

D. Wait until the client finishes the prayer and then complete the assessment

Which action would the nurse teach an older adult to take to prevent frequent colds (viral rhinitis)? a. Taking antihistamines as soon as symptoms begin b. Spending more time indoors during the cold season c. Wearing extra layers whenever going outside in winter d. Washing hands before putting them near the nose or mouth

D. Washing hands before putting them near the nose or mouth

Which pain scale would the nurse use when assessing a 4-year-old child? a. CRIES b. FLACC c. Numerical d. Wong-Baker

D. Wong-Baker

Which example is a one-on-one communication between the nurse and another person? a. Small-group communication b. Intrapersonal communication c. Interpersonal communication d. Transpersonal communication

C. Interpersonal communication