Nursing Concepts Advanced Test

a nurse working in a provider's office is reinforcing teaching with a client who is 36 wks gestation and has experienced a premature rupture of membranes. what statement would indicate she needs further teaching

"i will have my husband wear a condom during intercourse" there should be nothing entering the vaginal canal because of the increased risk for infection

a nurse is reinforcing teaching about client consent to newly licensed nurses. which of the following statements indicates a need for further teaching?

"it is the responsibility of the provider to obtain express consent"

a nurse working in a hospice facility is talking to a client's son who is distressed because his mother cries frequently and says she wants to die. which of the following responses is appropriate

"lets discuss some strategies you can use when this happens again" the nurse offers to provide information which can reduce anxiety and enhance decision making as well as creating a safe and secure environment that fosters trust and respect

a nurse is caring for a school-age child who is newly diagnosed with type 1 DM. which of the following actions is appropriate to prepare the child for administration of insulin

allow the child to manipulate the medical equipment by using age-appropriate strategies, the nurse allows the child to manipulate the equipment to facilitate mastery and give the child a sense of accomplishment.

a charge nurse on the ped unit is making assignments for a nurse who has floated from the labor and delivery unit. which client is appropriate for the charge nurse to assign?

an adolescent who is 2 days postop following an appendectomy the care of an adolescent who is 2 days post op requires care that comes from the basic/fundamental nursing skills and knowledge that all nurses have

a nurse is reinforcing teaching with the caregiver of a client who has aphasia. the nurse should include which communication strategies in the teaching

cue the client by providing picture cards that portray common needs aphasia patients have difficulty expressing themselves and understanding what is being said. using picture cards that portray common needs provides cues for the client and enhances communication

a nurse is caring for a client who is diabetic and being discharged home following an above knee amputation. which of the following health care professionals should be involved in the client's interdisciplinary team meeting

dietician, physical therapist, social worker dietician have expertise related to dietary contributions to maintaining health and treating dz and can offer the team suggestions that promote wound healing and muscle repair physical therapists have expertise related to musculoskeletal system and can implement therapeutic treatments that will rebuild and improve strength, teach new skills, and regain mobility social workers have expertise is working with clients and families to resolve issues that may arise due to health problems and can link client with community resources, assist with discharge plans, and resolve conflicts

a nurse is caring for an adult client who has attempted suicide. the client tells the nurse he is calling his family to come pick him up. which action by the nurse is appropriate?

discuss the risks associated with leaving with the client

a nurse is caring for a client admitted for acute alcohol delirium withdrawal 2 days ago. what is associated with this diagnosis?

elevated temperature

a nurse is caring for a pt who has had an acid-base imbalance. which manifestation is metabolic alkalosis a possible complication

excessive vomiting vomiting results in an excessive loss of acid from the body so if the patient is vomiting a lot, there would be less acid in the body resulting in metabolic acidosis

a nurse working in a provider's office is reinforcing teaching with a client who is 14 wks gestation. the nurse should instruct the pt to immediately notify the provider if she experiences what?

facial edema facial edema is an indication of pregnancy-induced hypertension

a nurse is caring for a neonate who was delivered at 30 weeks of gestation after his mother received two injections of betamethasone. because of the administration, the nurse should monitor the neonate for which effects?

hypoglycemia betamethasone is a glucocorticoid used in the prevention of respiratory distress syndrome in premature infants. betamethasone causes hyperglycemia in the mother, which predisposes the neonate to hypoglycemia in the first hour after delivery

a nurse is caring for a client who had a CVA 2 days ago. which of the following is the first sign of ICP?

lethargy

a nurse at a long term care facility is participating in a quality improvement project to reduce the occurrence of pressure ulcers. which audit should be conducted to determine the impact of a new skincare regimen?

outcome audit this type of audit is conducted to determine the actual result a specific nursing intervention has had on client outcomes

a nurse is caring for a child who has leukemia and is prescribed a transfusion of platelets. what is a result of the transfusion

reduced bleeding time platelets are responsible for triggering the process of blood clotting. clients who have leukemia are prone to bleeding because of a low platelet count, but when there is a transfusion of platelets a reduced bleeding time will be experienced as a result.

a nurse is caring for a child who is 24 hr post op following a supratentorial craniotomy. the nurse should maintain the child in which position

supine with head of bed elevated to 30 degrees following a supratentorial craniotomy, the client should be maintained in a position that facilitates drainage of cerebrospinal fluid and prevents hemorrhage by reducing blood flow to the brain

a nurse has assigned four tasks to an assistive personel (AP). what tasks should the nurse instruct the AP to perform first? take an ABG specimen to the lab pass out water to patients transfer a patient to get an xray

take an ABG specimen to the lab ABG samples are kept on ice and should be transported immediately to the lab or the specimen will deteriorate