Nursing 1

As part of an assessment, the nurse assesses the client's sensory experience. Which question would best assess sensory stimulation?

"Do you feel bored?"

A client newly diagnosed with type 2 diabetes mellitus states, "I just can't seem to win. Every time I turn around, I am being thrown a curve ball." Which questions should the nurse ask to determine the client's current ability to adapt to this new diagnosis? Select all that apply.

"How long have you felt like this?" "Do you have any other health problems?" "How do you usually cope with life problems?" "Have you told your doctor how you are feeling?"

The nurse attorney provides an educational session to the nursing staff on acts of negligence. Which responses by the staff would indicate to the attorney that the staff can accurately identify acts of negligence? Select all that apply.

"I can be charged with negligence if I apply a heating pad to the client's skin and the client suffers a superficial or first-degree burn." "I can be charged with negligence if I notify the health care practitioner about a change in a client's status but do not follow up or document.

A client asks the nurse how cortisol works. What is the appropriate nursing response?

"It suppresses the immune response."

The mother of three young children makes the following statements to the nurse working in community health. Drag and drop each statement in the order of priority from Maslow's basic priorities to Maslow's more complex priorities. Use all options.

"Sometimes we run out of food the day before I get paid." "There have been two murders in our neighborhood in the last year." "My teenage son is so quiet. He works and goes to school all the time and doesn't have time for friends." "I keep my kids' clothes clean, but we don't have money for the latest styles." "I try to get along with our neighbors, but they are from a strange culture with weird ideas."

The unlicensed assistive personnel (UAP) has taken vital signs on a newly admitted client. The client asks the nurse how this information is recorded in the chart, since the UAP is not licensed. Which response by the nurse is best?

"The UAP is able to log in and enter the information so all members of the health care team can see it."

Which question would be most helpful to the nurse in facilitating critical thinking during outcome identification and planning?

"What problems require my immediate attention or that of the team?"

Which IV solutions would the nurse expect to be ordered for a client who has hypovolemia? Select all that apply.

0.9% NaCl (normal saline) Lactated Ringer's solution 5% dextrose in 0.9% NaCl

A nurse is in the process of converting a continuous IV infusion to an intermittent infusion device. The nurse has clamped off the primary IV tubing, donned clean gloves, clamped the extension tubing and disconnected the primary IV tubing. The nurse is now cleansing the port on the extension tubing with an antiseptic swab. The nurse cleanses the port for which duration of time?

15 seconds

A nurse is measuring the intake and output of a client who is dehydrated. What is the average adult daily fluid intake in milliliters that the nurse would use as a comparison?

2,600 mL

The nurse is assessing a group of clients who were brought into the emergency department after a motor vehicle accident that resulted in a fire. Which client should the nurse give the highest priority for care?

A 45-year-old man with burns to the upper arms and chest and soot on the face who is restless and anxious

The nurse receives a client assignment. Which client should the nurse see first?

A client admitted with pneumonia, who is restless and diaphoretic with an oxygen saturation of 90%

In which clients has the order of priorities for nursing diagnoses changed? Select all that apply.

A client in a long-term care facility who had a stroke A client who insists on using the bathroom instead of a bedpan A client who appears confused after taking pain medication

Place the following examples of interventions to meet human needs in order from the most basic, high-priority needs to the lower-priority needs based on Maslow's hierarchy. Use all options.

A nurse provides nutrition for a client through a feeding tube. A nurse places a No Smoking sign on the door of a client who is receiving oxygen. A nurse includes family members in the care of a client. A nurse helps a client focus on the client's strengths following a diagnosis of breast cancer. A nurse prepares a room for a clerical visit requested by a client.

The nurse is caring for a client who reports throbbing pain at the site of a recent laceration from a pocketknife. How will the nurse document this type of pain? Select all that apply.

Acute Cutaneous

The nurse is caring for a client who had a below-the-knee amputation of the left leg 8 months ago. The client is reporting left foot pain of 7 on a 1-to-10 scale. The pain began earlier today. How will the nurse document this type of pain? Select all that apply.

Acute Neuropathic

The nurse is caring for a client who reports nausea and vomiting for 1 week. How will the nurse document this type of pain? Select all that apply.

Acute Visceral

A postoperative client who reported a pain level of 8 was medicated with an IV opioid 20 minutes ago. The client now reports a pain level of 9. Which would be the nurse's best action?

Administer a nonopioid medication

A client presents in the emergency department with signs and symptoms of venous thromboembolism. What type of medication administration would most likely be ordered to infuse a large dose of heparin for this client?

Administer heparin by intravenous bolus or push through an intravenous infusion.

Which action(s) by a licensed practical nurse (LPN) will illicit immediate intervention by the registered nurse (RN)? Select all that apply.

Administering packed red blood cells to a client with anemia Flushing an implanted central venous access device

A nurse is preparing to receive a client in post-anesthesia care unit (PACU). The client is diabetic and has undergone knee surgery. Which information would be most important for the receiving nurse to obtain to develop an appropriate plan of care for this client?

Amount of blood loss

During defecation, the client experiences decreased cardiac output related to the Valsalva maneuver. After the Valsalva maneuver, the nurse assesses the client's vital signs and expects to observe which of the following?

An increase in the client's blood pressure

A nursing student comes to the university health center reporting a sore throat, malaise, and loss of appetite. The nurse assesses the student and determines she has large, white-yellow exudates in the back of the throat and a fever. The student is presenting with:

An infectious disease

What phrase best describes the science of nursing?

Body of nursing knowledge

A nurse is auscultating the lungs of a client. During the auscultation, the nurse hears high-pitched, harsh, blowing sounds over the larynx and trachea. The nurse identifies these sounds as which type?

Bronchial breath sounds

The nurse must assess a client's systolic blood pressure using a Doppler ultrasound. Place the following steps to this procedure in the correct order. Use all options.

Center the bladder of the cuff over the artery, lining the artery marker on the cuff up with the artery. Wrap the cuff around the limb smoothly and snugly, and fasten it. Place a small amount of conducting gel over the artery. Place the Doppler tip in the gel and move it around until hearing the pulse. Inflate the cuff while continuing to use the Doppler device on the artery. Note the point on the gauge where the pulse disappears.

The nurse is caring for a client with terminal bone cancer. The client states, "My pain is getting worse and worse, and the morphine doesn't help anymore." The nurse determines the client's pain is:

Chronic malignant

Then nurse is preparing to apply a fecal incontinence pouch. Arrange the following steps in the correct order.

Cleanse entire perianal area and pat dry. Apply skin protectant and allow it to dry. Separate buttocks and apply the pouch to the anal area. Attach the pouch to a urinary drainage bag. Hang the drainage bag below the client.

The nurse is discharging several clients from an acute surgical unit on the same day. The nurse will prioritize teaching based on how much time is required for each client. Place the clients in the order, from first to last, in which the nurse will carry out discharge teaching. Use all options.

Client who is learning to draw up and inject insulin for the first time Client who indicates the live-in partner is a registered nurse Client who is being discharged to a long-term care facility Client who is being transferred to another unit in the hospital

The nurse is creating a concept map to plan for the care of a client. Place in order the steps the nurse will perform to create the concept map.

Collect client problems and concerns on a list. Connect and analyze the relationships. Create a diagram. Keep in mind key concepts. Apply the concept map to client care.

A nurse is caring for an older adult client who fell and sustained a hip fracture. Which intervention needs to be included in the nursing care plan? Select all that apply.

Cough and deep breathe every 2 hours. Avoid massaging over bony prominences. Auscultate breath sounds every 1-2 hours.

Which physiologic change occurs during non-rapid eye movement (NREM) sleep?

Decreased brain activity from wakefulness

The nurse is preparing to irrigate a client's abdominal wound following wound dehiscence. Arrange the presented nursing activities in the correct order. Use all options.

Discuss the procedure with the client and assess client knowledge. Gather equipment required for a dressing change. Drape the client to expose the area of the wound. Position the client to facilitate filling the wound cavity with solution Open and prepare supplies following the principles of surgical asepsis. Don gloves and other personal protective equipment. Fill the syringe with solution, and instill it into the wound. Dry the skin surrounding the wound.

A nursing unit was recently audited. Which findings would indicate to the nursing supervisor that the nurses are adhering to the principles of defensible charting? Select all that apply.

Documenting entries that are up to date and comprehensive Recording the date and time of all entries Using approved agency abbreviations

The nurse is providing care to a postoperative client who has a Jackson-Pratt (JP) drain. The nurse notes that the JP drain is expanded and full of sanguineous fluid. Place in order the steps the nurse will now perform. Use all options.

Don clean gloves. Empty the JP's contents into a graduated collection container. Compress the chamber and replace the JP cap. Note the amount of output, as well as its color. Remove gloves and sanitize or wash hands.

The nurse is admitting a client to the unit who needs frequent airway suctioning. Which precautions will the nurse select for the client?

Droplet

Organize these events in chronological order, beginning with the earliest (1) and ending with the most recent (5).

During the Crusades, religious orders provided nursing care to the sick. Florence Nightingale administered care to British soldiers during the Crimean War. Mary Eliza Mahoney graduated from the New England Hospital for Women and Children as America's first African American nurse. Clara Barton organized the American Red Cross. Margaret Sanger advocated for contraception and family planning in the United States.

The client is experiencing respiratory distress and the nurse places the client in a high Fowler position. Which action does the nurse take next?

Ensure airway patency

A nurse is reviewing a journal article about basic human needs and how they can be applied as a framework for prioritizing nursing care. Place the interventions listed below in order of priority, based on client needs. Use all options.

Ensuring adequate fluid intake Encouraging the client's spiritual practices Referring the client to a support group Encouraging the client to set attainable goals Providing education focusing on the client's strengths to maximize potential

In human beings, the physiologic response to a stressor includes the:

Epinephrine increasing the blood-glucose level.

The nurse performed a physical lung assessment on a client who reports shortness of breath. The nurse collected the following data. What is the proper sequence of data collection?

Exhalation is prolonged. Respirations are 24 breaths/minute. Chest is barrel shaped. Skin on chest is warm and dry. Decreased tactile fremitus is present. Percussion reveals hyperresonant sounds. Chest excursion is less than normal. Breath sounds are adventitious in lower lobes.

A nurse asks a young adult questions about family, friends, and support systems based on Erikson's stages of psychosocial development. What is the reason this information is important during assessments of young adults?

Fear of commitments may lead to loneliness and isolation.

The nurse is assessing a postoperative client who is recovering from anesthesia. Which signs should the nurse interpret as indicating that peristalsis is returning in the client? Select all that apply.

Flatus Presence of bowel sounds

The evolution of nursing research has significant markers in time. Place the following events in the correct order.

Florence Nightingale kept records while caring for victims of the Crimean War. Nursing research was deemed to be increasingly important, and research was utilized for the development of nursing practice standards. Clinical research became the emphasis of nursing research resulting in procedures for primary client care, such as vital signs and treatments. The National Institute for Nursing Research funded research for the scientific basis for client care.

The nursing instructor is explaining how the respiratory system is involved in hydrogen ion regulation to maintain normal pH. Place the steps in order once the CO2 in the blood has increased, resulting in increased respirations to eliminate CO2.

H2CO3 level in the blood decreases pH becomes more alkaline Blood level of CO2 decreases Decreased respirations Carbon dioxide retention Carbonic acid formed

The action of ibuprofen is to:

Have an antiprostaglandin effect on the CNS.

A nurse is providing care to a client with hypocalcemia. The nurse would monitor the client's laboratory test results for which imbalance?

Hyperphosphatemia

The client is sleeping, and arousal is easy. Occasionally, the client exhibits involuntary muscle jerking, which appears to startle the client. Vital signs are unchanged from 1 hour ago. The nurse assesses the stage of nonrapid eye movement (NREM) sleep, which the client exhibits as Stage:

I.

The nurse is preparing to attach a label to an intravenous medication that is being administered by continuous infusion. Which component will the nurse include on the label? Select all that apply.

Identification of drug Dose Time drug was added Initials of nurse

The nurse is caring for an older adult with pneumonia. What action by the nurse will help the client prevent further pulmonary infections?

Immunize the client with the pneumococcal vaccination once in a lifetime

Which body system effects would the nurse state as occurring due to immobility? Select all that apply.

Increased cardiac workload Increased risk for renal calculi Increased risk for electrolyte imbalance

When completing an assessment of the middle-aged adult, the nurse makes note of the client's cognitive development. Then nurse would expect to find what?

Increased motivation to learn.

A nurse is explaining the process of infection to a nursing student. Place the process in the mostappropriate order.

Infectious agent A reservoir An exit route Transmission mode Entry portal Susceptible host

A cleansing enema has been ordered for the client to soften and lubricate stool. Which type of solution does the nurse gather?

Mineral oil

A home care nurse is visiting one of her elderly clients. Which of the following does the nurse do to screen for chronic illnesses common to the elderly? Select all that apply.

Monitor blood pressure Perform blood glucose monitoring Assess joint mobility and presence of pain

The nurse is teaching a client and caregiver how to properly use an incentive spirometer. Place the following steps in the correct order. Use all options.

Note the goal for inhalation Exhale normally Seal the lips around the mouthpiece Inhale slowly until reach desired volume Hold breath for 4 seconds Remove mouthpiece and breathe normally

The nurse is caring for an older client who is ordered restraints. What is the priority nursing action?

Offer the client bathroom privileges and assistance

A nurse must take a client's pulse oximetry reading. The nurse is explaining the technique to the client. Which statements about pulse oximetry are true? Select all that apply.

Once the oximetry probe is correctly placed, a beam of red and infrared light travels through the tissue and blood vessels. Sensors are available for use on the finger, toe, foot, earlobe, forehead, and bridge of the nose.

Place the following levels of needs in the correct ascending order (starting with the most basic as 1) according to Maslow's hierarchy of basic human needs.

Physiologic needs Safety and security needs Love and belonging needs Self-esteem needs Self-actualization needs

The nurse is preparing to assess a client's postvoid residual using a bladder scanner. Place the following steps in the correct order. Use all options.

Press the appropriate gender button. Position the scanner head with directional arrow pointing to the head. Press scanner head onto the skin 1 to 1.5 inches (2.5 to 3.75 cm) above the symphysis pubis. Aim the scanner head toward the coccyx and activate the scan. Verify that screen crossbars fall within the bladder image. Observe and record the volume measurement on the screen.

A nurse is performing a physical assessment for an older adult client who recently had a hip replacement. In what position would the nurse place this client to examine the hip joint?

Prone

The nurse is providing care for a client whose diagnosis requires the nurse to use personal protective equipment (PPE). Place the steps in the order in which the nurse will perform the actions.

Provide instruction about precautions to client, family members, and visitors. Perform hand hygiene. Put on the gown, with the opening in the back. Tie gown securely at neck and waist. Put on the mask or respirator over your nose, mouth, and chin. Put on goggles and place over eyes and adjust to fit. Put on clean, disposable gloves and extend gloves to cover the cuffs of the gown.

A nurse is caring for a client with burns. Place the steps in the appropriate order for providing wound care for the client. Use all options.

Remove old dressing. Assess condition of wound. Obtain a culture. Open sterile dressing tray. Change from clean to sterile gloves. Record color and odor of discharge.

The client cut his leg on a gardening tool several days ago and is being seen for an infected wound. The nurse is going to obtain a culture of the wound and then re-dress the wound. What are the steps, in order, for the nurse to obtain the wound culture and re-dress the wound? Arrange the following steps in the correct order.

Remove the soiled dressing wearing clean gloves. Clean the wound, wearing sterile gloves and using sterile supplies. Dry the surrounding tissue with gauze. Insert the culture swab deep into the wound, wearing clean gloves. Using a different pair of gloves, place a clean dressing on the wound.

Put the steps of the clinical reasoning cycle in the correct order.

Review current information. Analyze data to come to an understanding of signs or symptoms. Match current clients to past clients. Describe what the nurse wants to happen, a desired outcome, a time frame. Select a course of action between different alternatives available. Evaluate the effectiveness of actions.

The nurse is caring for a client who has had unrelieved back pain for 3 years. How will the nurse document this type of pain? Select all that apply.

Somatic Chronic

A nurse monitoring an IV infusion notes the signs and symptoms of a thrombus. Which nursing interventions would the nurse perform? Select all that apply.

Stop the infusion immediately. Apply warm compresses as ordered by the primary care provider. Restart the IV at another site.

The nurse recognizes which routes for parenteral medication administration? Select all that apply.

Subcutaneous Intramuscular Intradermal Intravenous

When first diagnosed with cancer, a client was depressed and complained of feeling sick. Now the client has adapted to the diagnosis, recently returned to work, and, since undergoing chemotherapy, reports feeling better than ever. The nurse recognizes that which model of health promotion is most effective in explaining this client's situation?

The Health-Illness Continuum Model

The client has experienced a fasting blood sugar in excess of 300 mg/dL (16.65 mmol/L) and is now diagnosed as having diabetes. The nurse writes nursing diagnoses related to deficient knowledge. Place in order the actions of using the nursing process for this client. Use all options.

The client's blood sugar is over 300 mg/dL (16.65 mmol/L). The client is diagnosed as having diabetes. The nurse assesses the client's understanding as having no previous exposure to diabetes or care to manage health problems. The nurse analyzed the data and determined this client has multiple problems requiring education. The nurse writes one of the nursing diagnoses as Deficient Knowledge related to client's lack of exposure as evidenced by verbalizing inaccurate information. The nurse addresses the client's learning needs by writing outcomes and education plans that involve disease process, self-monitoring of blood glucose, medications, diet, and checking the feet daily. The nurse teaches the client addressing all domains—affective, cognitive, and psychomotor. The nurse evaluates the client as achieving or not achieving each outcome.

The client is a parent who has just been notified their son was in a motor vehicle accident. The nurse assesses the following reactions of the client over time. Place the reactions in the order of the stages of the general adaptation syndrome (GAS).

The client's pupils are measured at 5 mm from original 3 mm. The client's heart rate decreases from 116 to 84 beats/min. The client reports a feeling of exhaustion. The client states she feels rested after sleeping.

The nurse is planning a diet for a client with chronic obstructive pulmonary disease (COPD). Which recommended nutritional guidelines would the nurse discuss with the client? Select all that apply.

The diet should consist of 40% to 55% carbohydrates. The diet should be rich in antioxidants and vitamins A, C, and B. The diet should contain 12% to 20% protein.

The nurse has assessed a pulse deficit when taking the pulse of a client. What does this assessment indicate for the client? Select all that apply.

The difference between apical and peripheral pulse rate The apical pulse is higher than the radial pulse. The health care provider should be notified of any increase in pulse deficit.

The nurse is using the nursing process to plan care for a client who has just been admitted to the hospital. Place in order the steps of the nursing process that the nurse would use for this client. Use all options.

The nurse observes that the client is short of breath, coughing, and expectorating thick, yellow sputum. The nurse analyzes the data and determines that the client is experiencing an oxygenation problem. The nurse plans to teach the client about deep breathing, coughing sputum into a tissue, and disposing of the tissue in an appropriate receptacle. The nurse administers an intravenous antibiotic every 12 hours. The nurse evaluates lung sounds and vital signs for effectiveness of treatment.

A nurse is assessing the bowel elimination patterns of hospitalized clients. Which nursing actions related to the assessment process are performed correctly? Select all that apply.

The nurse places the client in the supine position with the abdomen exposed. The nurse uses a warmed stethoscope to listen for bowel sounds in all abdominal quadrants. The nurse notes the character of bowel sounds, which are normally high-pitched, gurgling, and soft.

Place the following nursing interventions in order of priority according to Maslow's hierarchy of basic needs.

The nurse teaches the client about foods high in fiber. The nurse teaches the client's daughter how to safely administer the client's insulin. The nurse assists the client in making a phone call to the client's daughter. The nurse positions the bed of the Muslim client who is bedfast toward Mecca.

A client has developed dysphagia secondary to a cerebrovascular accident. Which precautions should the nurse initiate to prevent choking during meals?

Thicken liquids with commercial products.

A client is requesting to view all medical record information regarding the care received while hospitalized. What rights does the client have regarding accessing the medical record according to HIPAA regulations? Select all that apply.

To see the health record To copy the health record To restrict certain disclosures of the health record

An order was made for a client who is cognitively impaired to have a nitroglycerin transdermal patch. On which area of the body is the nurse expected to place the patch?

Upper back

The nurse is removing soiled gloves after assisting with a sterile procedure. Which actions follow recommended guidelines for this procedure? Select all that apply.

Use the dominant hand to grasp the opposite glove near cuff end on the outside exposed area. Remove the glove by pulling it off, inverting it as it is pulled, and keeping the contaminated area on the inside. Slide the fingers of the ungloved hand between the remaining glove and the wrist. Discard the gloves in appropriate container, removing additional PPE, if used, and performing hand hygiene.

A client describes difficulty falling asleep and difficulty maintaining sleep, and reports daytime fatigue and inability to concentrate. The nurse suggests which noninvasive techniques that may help promote restful sleep? Select all that apply.

Waking at the same time every morning Removing bedtime distractions such as watching television in bed Practicing relaxation techniques

Which scenario describes how carbon dioxide levels determine the frequency and depth of ventilation?

When carbon dioxide levels in the blood increase, chemoreceptors are stimulated, causing deeper and more rapid breathing.

A nurse is teaching a client who has unilateral weakness how to walk with a cane. Which guideline promotes safe use of this device?

When taking a step forward, the heel of the client's foot should be slightly beyond the tip of the cane.

The student is studying the sensory experience. Which statement indicates that the student understands the four conditions that must be met for a client to experience the world?

"An agent, act, or other influence capable of initiating a response by the nervous system must be present."

A physical examination on a client should always include which components? Select all that apply.

Appraisal of health status Identification of health problems Establishment of a database for interventions

When collecting subjective and objective data for a database in a client's home, it is important to:

Ask the client to turn off the television.

A registered nurse plans to return to the nursing profession after a long hiatus. Which statement about the trend in health care services would be most important for the nurse to keep in mind?

Clients enter the health care system acutely ill.

The nurse is caring for a client who has been placed in physical restraints. Which nursing action is appropriate? Select all that apply.

Communicate with the family regarding the need for restraints. Check circulation and skin condition frequently and regularly. Offer opportunities for toileting frequently and regularly.

A client is admitted to the emergency department with shortness of breath and oxygen saturation of 88%. The client has a barrel chest and clubbed fingers. What is the nurse's priority intervention?

Place client in the tripod position

The nurse is caring for a client postoperatively. The vital signs are blood pressure 88/50 mm Hg, heart rate 110 beats/min, respiratory rate 24 breaths/min. The client stated the pain in the abdomen will not stop. The abdominal dressing is saturated with fresh blood. Along with notifying the surgeon, what is the nurse's priority in this situation?

Place in supine position.

Which step in the nursing process is most closely associated with cognitively skilled nurses?

Planning

Which nursing diagnosis is the priority according to Maslow's hierarchy of basic needs?

Constipation related to decreased mobility

A physician orders an enema to effect rapid colonic emptying in a client who is experiencing severe abdominal cramping due to constipation. Which type of solution would be best suited to this client's needs?

Large-volume cleansing enema with hypotonic solution

The nurse is preparing to transfer a client from the bed to a stretcher. What action should the nurse take to prevent injury to the client and nurse?

Leave the friction-reducing sheet in place once the client is transferred

A nurse is caring for a postoperative client. What intervention(s) will help prevent thrombophlebitis? Select all that apply.

Leg range of motion exercises Sequential compression devices (SCDs) and antiembolic stockings Early ambulation as tolerated Frequent turning and positioning

The nurse is providing discharge education for a client diagnosed with hypertension. Which teaching points about monitoring blood pressure should the nurse include in the plan? Select all that apply.

Recommend taking the blood pressure every day at the same time. Recommend a cuff size appropriate for the client's limb size. If using a forearm monitor, tell the client to keep wrist at heart level when using it.

A client is newly prescribed a nitroglycerin transdermal patch daily. Which should the nurse include when educating a client on how to administer this drug? Select all that apply.

"Rotate the location of the patch daily." "Clean the area when removing the old patch." "Wrap removed patch in plastic and dispose."

A nurse is caring for a client with a complete spinal cord injury that has caused paraplegia. The client is very distraught and asks the nurse, "Are they sure, even with therapy, I will never walk again?" Which statement made by the nurse demonstrates veracity?

"You have a complete injury, which results in a total loss of movement and sensation below the level of injury."

A nurse monitoring the intake and output of fluids for a client with severe diarrhea knows that normally how much body fluid is lost via the gastrointestinal tract?

300 mL

Martin is a 58-year-old smoker who was admitted to the hospital with worsening shortness of breath over the last 2 days. He states that he is having some chest discomfort. The nurse asks him further about this in order to characterize whether this may be cardiac related, musculoskeletal related, or respiratory related. Martin states that when he breathes in, he feels as if the air passing into his lungs is burning him. It is also very painful to swallow. Based on what Martin is stating, which illness does the nurse suspect is causing Martin's chest discomfort?

Acute bronchitis

A nurse is assessing a family and observes that the family demonstrates behaviors that assist its members in establishing their identities. The nurse interprets this behavior as fulfilling which family function?

Affective

The nurse is caring for a client who has had abdominal surgery. Which intervention(s) will the nurse include to prevent complications for this client? Select all that apply.

Assist the client with the use of incentive spirometry. Turn the client and change position frequently. Administer analgesic medication as required.

A postoperative client is experiencing decreased lung sounds, dyspnea, cyanosis, crackles, restlessness, and apprehension. Which condition would the nurse suspect?

Atelectasis

The nurse is providing care for a client who experienced an ischemic stroke 5 days ago. The client now has difficulty swallowing liquids and solids, has weakness on the right side of the body, and is incontinent of bowel and bladder. Which priority nursing diagnoses should the nurse identify and document in the care of this client? Select all that apply.

Bowel Incontinence Impaired Swallowing Impaired Physical Mobility

While conducting a physical examination of the thorax, a nurse notes and documents breath sounds as moderate "blowing" sounds with equal inspiration and expiration. What type of breath sounds are these?

Bronchovesicular

An occupational health nurse is planning in-service training sessions for the employees. Which teaching topic would be most appropriate to cover with these clients?

Cardiopulmonary resuscitation

What national organization determined that unintentional injuries were the fifth-leading cause of all deaths in the United States?

Centers for Disease Control and Prevention

The nurse is asked to check the unit's supply of personal protective equipment (PPE) to see if additional equipment needs to be ordered from central supply. The nurse should assess the level of which type of equipment? Select all that apply.

Nonsterile gloves Masks Gowns Protective eyewear

The nurse desiring to use laughter as a therapeutic modality for pain should assess for which therapeutic effects?

Decreased levels of epinephrine Increased pain threshold Increased ability to face difficult procedure

Which are appropriate guidelines for the nurse to follow when delegating tasks to an unlicensed assistive personnel (UAP)? Select all that apply.

Delegate tasks that are within the UAP's scope of practice. Delegate tasks that involve minimal risk. Provide appropriate supervision when delegating tasks. Provide feedback to the UAP after the task is completed.

A nurse is explaining to an insomniac client the effect of a prescribed medication and the different phases of sleep. Which statement is true for nonrapid eye movement (NREM) sleep?

It is called slow wave sleep.

The nurse is teaching a client about enoxaparin sodium for the first time. This client has never given a self-injection before. Which action(s) are appropriate for the nurse to take? Select all that apply.

Have the client demonstrate the proper technique for injection. Provide a printed diagram highlighting the injection site. Gather all necessary supplies for injection teaching. Review medication data sheets to ensure correct dosage.

Arterial blood gases reveal that a client's pH is 7.20. What physiologic process will contribute to a restoration of correct acid-base balance?

Increased respiratory rate

A nurse is caring for a client who has pneumonia. What is an appropriate nursing diagnosis?

Ineffective Airway Clearance

The nurse is caring for a client who has just had a lower leg amputation following a motor vehicle accident. During the planning phase of the nursing process, the nurse will prioritize which problem(s) on the first postoperative day? Select all that apply.

Infection risk Impaired coagulation potential

The nurse is preparing to complete the admission assessment on a new client. Which factor(s) should the nurse include when assessing the client's cultural needs? Select all that apply.

Is the client comfortable with accepting help from strangers? Does the client wear special clothing? What method does the client prefer to use to make decisions?

A nurse asks a client to rate the pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. Which information will the nurse gather next to establish the client's baseline pain experience?

Location

A client is experiencing withdrawal from alcohol and admitted to the behavioral health unit. The client begins to have muscle weakness, tremors, hyperactive deep tendon reflexes, and a change in mental status. What should the nurse prepare to replace in this client?

Magnesium

The nurse is implementing comfort measures to promote sleep for a client. Which intervention is the best choice for the client?

Offer client a small carbohydrate and protein snack before bedtime.

In which age group do interpersonal losses play a role in disturbances in self-concept?

Older adult

An 18-year-old client is brought to the urgent care clinic reporting severe left leg pain. Which assessment(s) should the nurse prioritize for this client? Select all that apply.

Pedal pulses Skin color Temperature of skin Tenderness to palpation

A client who has a bacterial infection develops an abscess that needs to be drained. What drainage system would most likely be used in this situation?

Penrose drain

The nurse is performing wound care on a wound that tested positive for methicillin-resistant Staphylococcus aureus (MRSA). What is the most effective way for the nurse to apply the principles of infection control?

Perform hand hygiene after removing gloves

The physiologic and biochemical effects of a drug on the body defines:

Pharmacodynamics

A nurse is reviewing the nurse practice act of the state in which the nurse is licensed. The nurse understands that this act was derived from which source of law?

Statutory

A nurse is collecting a urine specimen for urinalysis. Which factors should the nurse consider when performing this procedure? Select all that apply.

Sterile urine specimens may be obtained by catheterizing the client's bladder. Strict aseptic technique must be used when collecting and handling urine specimens. A clean-catch specimen of urine may be collected in midstream.

The nurse has completed an assessment of a client who has had difficulty sleeping for more than 3 months. The nurse has diagnosed the client as having the nursing diagnosis Insomnia. What data supports this diagnosis? Select all that apply.

Swelling of the client's eyelids 10 lb (4.5 kg) overweight; an increase of weight noted in the past 3 months Yawning during the assessment interview

When preparing to administer a large cleansing enema to a client, which solution does the nurse gather?

Tap water

The registered nurse (RN) notices that client assignments are not being made fairly. The charge nurse is responsible for making the client assignments and has a reputation for being argumentative. Who should the RN consult regarding the unfair client assignments?

The charge nurse

The nurse is responsible for recognizing significant data when developing nursing diagnoses. Which significant data would indicate a health problem may exist? Select all that apply.

The client has a blood pressure reading of 150/90 mm Hg. During assessment, the client is sweating and short of breath. The client only answers yes or no questions.

The nurse uses the nursing process to provide care to clients. What are the benefits for the clients? Select all that apply.

The client receives care that is evidence-based. Care is individualized for the client. The nurse provides care that is consistent for the client.

The nursing team, consisting of a nurse and experienced unlicensed assistive personnel (UAP), have worked well together for the past year. The nurse instructs the UAP to feed a stable stroke client, assist with dressing a client in preparation for discharge, and take vital signs of a third client in addition to notifying the nurse if the blood pressure becomes low. Which error has the nurse made?

The nurse failed to communicate clear instructions regarding what constitutes a low blood pressure.

Which situation violates an element of informed consent?

The nurse says, "You have to sign this before we can do the surgery."

A nurse is preparing to remove the staples from the donor vein site on a client's leg following cardiac surgery. Which guideline should inform the nurse's decision making?

The nurse should apply adhesive wound closure strips after removing staples.

A nurse assessing a client's respiratory effort notes that the client is breathing 8 shallow breaths/min. Which action best meets this client's immediate oxygenation needs?

Use a bag and mask.

An adolescent informs the nurse at the clinic, "I do not know what is happening to me, my skin is turning very white in spots all over my hands." The nurse assesses hypopigmented areas on the hands and documents the finding. Following evaluation by the health care provider, what education will the nurse provide to the client?

Using a pigmented cream will help to even the skin tones.