PN13 Midterm

An alert oriented client voided incontinently soiling clothing. What action by the nurse is a priority A.Inform the client to use the bathroom next time. B. Provide assistance with washing and changing clothing C. Tell the client that an adult diaper must be worn D. Insert an indwelling catheter

Provide assistance with washing and chaging cloths

The nurse is discussing the family tasks that are critical for survival and continuity. Which task identified by a family member would take priority? A. Providing financial support for healthcare needs B. Establishing emotional bonds C. Developing recognition for achievements D. Providing food, shelter, and clothing

Providing food, shelter, and clothing

The nurse caring for a client who states " I am having discomfort in my lower back from lying in bed " What independent nursing action can the nurse provide? Independent think do by yourself no order A. Administer 60mg Tylenol mg po. B. Reposition the client in bed for comfort C. Apply mparseedicated patch to lower back D. Administer an opioid analgesic

Reposition the client in bed for comfort

Interpersonal skills

Skills that promote relationships with other people

A nurse is preparing a health promotion course for a group of middle adults. Which of the following strategies should the nurse recommend? Select all that apply A: Eye examination every 1 to 3 years B: Decrease intake of calcium supplements C: DEXA screening for osteoporosis D:Increase intake of carbohydrate in the diet E: Screening for depressive disorders

A: Eye examination every 1 to 3 years C: DXA screening for osteoporosis D: Increase intake of carbhydrate in the diet E: Screening for depressive disorders

A nurse is collecting history and physical examination data from a middle adult. The nurse should expect to find decreases in which of the following physiologic functions? Select all that apply A: Metabolism B: Ability to hear low pitched sounds C: Gastric secretions D: Far vision E: Glomercular filtration

A: Metabolism C: Gastric secretions E: Glomercular filtration

A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? Select all that apply A: Planning and evaluating control and prevention strategies B: Determining public health priorities C: Ensuring proper medical treatment D: Identifying endemic disease E: Monitoring for common source outbreaks

A: Planning and evaluating control and prevention strategies B: Determining public health priorities C: Ensuring proper medical treatment E: Monitoring for common source outbreaks

Heart sounds

APE to MAN aortic pulmonic erb's point tricuspid mitral

A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority? A. " I spent my whole life dreaming about retirement, and now I wish I had my job back." B. "Its been so stressful for me to have to depend on my son to help around the house." C. "I just heard my friend Al died. That's the third one in 3 months." D. "I keep forgetting which medications I have taken during the day."

" I keep forgetting which medications I have taken during the day"

A nurse is counseling a middle adult client who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further? A. " I am struggling to accept that my parents are aging and need so much help." B. "It's been so stressful for me to think about having intimate relationships." C."I know I should volunteer my time for a good cause but my i'm just selfish." D. "I love my grandchildren, but my son expects me to relive my parenting days."

"Its been so stressful for me to think about having intimate relationships"

A client states " I feel nauseous " after a surgical procedure. What is an appropriate dependent nurse action to implement for this client ? Dependent think need order (like your child depends on you so you will need an order to do it) A. Place an emesis basin where the client can reach it. B. Elevate the head of the bed to 45 degrees C. Apply a cool, damp cloth to the forehead. D. Administer an antimetic as ordered.

Administer an antiemetic as ordered

Which of the following clients should the nurse monitor more closely for signs of developing depression? A. A 58 year old Hispanic female raising a grandchild B. A 70-year old married African American male C. A 68-year old Caucasian male that lives alone D. A 46-year old married mother of three.

A 68 year old caucasian male that lives alone

A newly licensed nurse is reporting to the charge nurse about the care she gave to a client. She states, "The client said his leg pain was back, so I checked his medical record, and he last received his pain medication 6 hours ago. The prescription reads every 4 hours PRN for pain, so I decided he needs it. I asked the unit nurse to observe me preparing and administering it. I checked with the client 40 minutes later, and he said his pain is going away." The charge nurse should inform the newly licensed nurse that she left out which of the following steps of the nursing process? A. Assessment B. Planning C. Intervention D. Evaluation

A. Assessment Always evaluate the patients severity of pain on the pain scale 0 to 10 and the characteristics of pain assessed for any changes that might have contributed to worsening of the pain.

By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? A. Reassess the client to determine the reasons for inadequate pain relief. B. Wait to see whether the pain lessens during the next 24 hr. C. Change the plan of care to provide different pain relief interventions. D. Teach the client about the plan of care for managing his pain.

A. Reassess the client to determine the reasons for inadequate pain relief. The nurse should collect futher data on the client to determine why he has not achieved satisfactory pain relief because various factors might be interfering with his comfort. The nursing process repeats in an ongoing manner across the span of client care.

A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? Select all that apply. A. Respiratory rate is 22/min with even, unlabored respirations B. The client's partner states, "He said he hurts after walking about 10 minutes." C. Pain rating is 3 on a scale of 0 to 10 D. Skin is pink, warm, and dry E. The assistive personnel reports the client walked with a limp.

A. Respiratory rate is 22/min with even, unlabored respirations. D. Skin is pink, warm, and dry E. The assistive personnel reports the client walked with a limp These are all objective because they can be proven, or assessed.

A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (Select all that apply.) A. A bottle containing a sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand The nurse must prepare the sterile solution before putting on the sterile gloves. The 1 inch border on the outer edge of the sterile field is not sterile.

Any object the nurse drops onto the sterile field is sterile and can be touched with sterile gloves C. The inner wrapping of an item on the sterile field are sterile D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand because both are sterile

A nurse is reviewing hand hygiene techniques with a group of (AP) assistive personnel. Which of the following instruction should nurse include when discussing hand washing ? Select all the apply. A. Apply 3 to 5 ml of liquid soap to dry hands B. Wash hands with soap and water 15 seconds. C. Rinse hand with HOT water. D. Use a clean paper towel to turn off hand faucets. E. Allow the hands to air dry.

B. Wash hands with soap and water 15 seconds this is the amount of time it takes to remove dirt and for very soiled hands its 2 min. D. Use a paper towel to turn off hand faucets not their hands.

A nurse is teaching a young adult client about health promotion and illness prevention. Which of the following statment by the client indicate an understanding of the teaching? A: "I already had my immunizations as a child so Im protected in that area" B: "It is important to schedule rountine health care visits even if I am feeling well" C: "I will just go to an urgent care center for my routine medical care" D: "Theres no reason to seek help if I am feeling stressed because its just part of life"

B: "It is important to schedule rountine health care visits even if I am feeling well"

A nurse is collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as associated with aging? Select all that apply A. Skin thickening B. Decreased height C. Increased Saliva production D. Nail Thickening E. Decreased bladder capacity

B: Decrease height D: Nail thickening E: Decrease bladder capacity

A nurse is planning a presentation for a group of older adults about health promotion and disease prevention. Which of the following interventions should the nurse plan to recommend? Select all that apply A, Human Papilloma Virus (HPV) B. Pneumococcal Immunization C. Yearly eye exam D. Periodic mental health screening E. Annual fecal occult blood test.

B: Pneumococcal immunization C: Yearly eye exam D: Periodic mental health screening E: Annual fecal occult blood test

A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include to address common health risks for this age group? Select all that apply A. Install bath rails and grab bars in bathroom B. Wear a helmet while skiing C. Install a carbon monoxide detector D. Secure firearms in a safe location E. Remove throw rugs from the home.

B: Wear a helment while skiing C: Install a carbon monoxide detector D: Secure firearms in a safe location

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include in the plan of care? Select all that apply A: Place the client in a room that has negative air pressure of at least six exchanges per hour B: Wear a mask when providing care within 3 feet of the client C: Place a surgical mask on the client if transporation to another department is unavoidable D: Use sterile gloves when handling soiled linens E: Wear a gown when performing care that might result in contamination from secretions

B: Wear a mask when providing care within 3 feet of the client C: Place a surgical mask on the client if transporation to another department is unavoidable E: Wear a gown when performing care that might result in contamination from secretions

Nurse has prepared sterile field for assisting provider with chest tube insertion. Which should nurse recognize as contaminating sterile field? (Select all that apply.) A: provider drops sterile instrument onto near side of sterile field As long as the provider has not reached over the sterile field the field remains sterile. B: nurse moistens cotton ball with sterile NS & places it on sterile field C: procedure is delayed 1h b/c provider receives emergency call D: nurse turns to speak to someone who enters through door behind nurse E: client's hand brushes against outer edge of sterile field The 1 inch border at the outer edge of the sterile field is not sterile. Unless the client reached farther into the field the field remains sterile.

B: nurse moistens cotton ball with sterile NS & places it on sterile field Fluid of a sterile drape or barrier contaminates the field C: procedure is delayed 1h b/c provider receives emergency call Prolong exposeure to air contaminates the field. D: nurse turns to speak to someone who enters through door behind nurse Turning away from the filed contaminates it because the nurse can not see if something may have contaminated the field.

Dependent actions

Based on orders or specific directions from the healthcare provider

A client has been prescribed an antibiotic for a bacterial infection. What information is important for the nurse to tell the client ?

Be sure to complete the drug for the entire period prescribed even if the symptoms are better

A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? Select all that apply. A. Writing a prescription for morphine sulfate as needed for pain. B. Inserting a nasogastric (NG) tube to relieve gastric distention C. Showing a client how to use progressive muscle relaxation. D. Performing daily bath after the evening meal. E. Repositioning a client every 2 hours to reduce pressure ulcer risk.

C. Showing a client how to use progressive muscle relaxation. D. Performing daily bath after evening meal E. Repositioning a client every 2 hours to reduce pressure ulcer risk.

A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the charge nurse should include as a developmental task for a young adult? A. Becoming actively involved in providing guidance to the next generation B. Adjusting to major changes in roles and relationships due to losses. C. Devoting a great deal of time to establishing an occupation D. Finding oneself "sanwhiched" between being responsible for two generations.

C: Devoting a great deal of thime to establishing an occupation The nurse should identify exploring career options and then establishing oneself in a specific occupation as a major development task for a yound adult

Presbycusis

Changes in hearing

Presbyopia

Changes in vision

A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closest to the body B. The right side flap C. The left side flap D. The flap farthest from the body A. The flap closest to the body is the last flap to unfold

D the flap farthest from the body

A nurse is caring for a client who presents with linear clusters of fluid containing vesicles with some crustings. The nurse should identify the client has manifestations of which of the following conditions? A: Allergic reaction B: Ringworm C: Systemic lupus erythematosus D: Herpes zoster

D: Herpes zoster Vesicles that follow along a unilateral dermatome is a manifestation of herpes zoster

A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. Which of the following examples should the nurse include as a developmental task for middle adulthood? A. The client evaluates his behavior after a social interaction. B. The client states he is learning to trust others. C. The client wishes to find meaningful friendships D. The client expresses concerns about the next generation.

D: The client expresses concerns about the next generation Ericksons task for middle adult as generativity vs. stagnation. The nurse should include showing concern for next generation as an example for this age group.

A hospitalized client has been taking antibiotics for several days and develops Clostridium difficile.(C-Diff) What symptoms of this infection should the nurse provide care for? A. Cough B. Diarrhea C. Vomiting D. Vaginal Discharge

Diarrhea

The nurse is preparing to perform a dressing change for a client who has an open surgical wound of the abdomen. What is the most appropriate action by the nurse when finding the seal on the sterile 4X4 dressing package is broken? A. Discard the 4x4 closest to the broken seal and use the others. B. Proceed with using the 4x4's C. Discard them and obtain a new package. D. Use them for the outside of the dressing only.

Discard them an obtain a new package

A middle aged client is experiencing some age related skin changes. What is priority action by the nurse related to these changes? A. Tell the client to be checked every 3 months for skin changes B. Inform the client that there are no problems related to the changes. C. Discuss with the client normal vs. abnormal changes. D. Inform the client that the age spots on the hands can be cancerous.

Discuss with the client normal vs. abnormal changes

The nurse is talking with an eldest adult client and the client states. "I have done so many things in life and was able to achieve my goals" What developmental stage has this client achieved? A. Ego integrity B. Despair C. Stagnation D. Generativity

Ego intergrity ???

The nurse overhears an elder adult client saying to another client , :I feel depressed because I have so many regrets about my life" What activity can the nurse provide to help this client gain a positive perspective? A. Proved a craft project B. Encourage ambulation C. Provide a game such as Bingo. D. Encourage reminiscence.

Encourage reminiscence

When obtaining data from a client, the nurse ask, "who do you live with?" The client states, "I live with my parents, brother, and grandparents" What documentation is appropriate to describe the family structure? A. Nuclear Dyad B. Extended Family C. Binuclear Family D. Blended Family

Extended family

When the nurse goes into a clients room to change a dressing. She notices the client is coughing and sneezing. Which of the following actions shoud she take while preparing the sterile field? It would be difficult for the nurse to maintain a sterile field away from the bedside. The client might be unable to stop coughing and sneezing during the dressing change. Keeping tissues close by for the client to use will contaminate the surgical wound.

Place a mask on the client prevents contamination of the surgical wound during dressing change.

A senior adult nurse wishes to mentor the younger new nurse and asks the supervisor for permission to be a mentor. What developmental stage according to Erickson is the senior nurse experiencing? A. Stagnation B. Generativity C. Integrity D. Despair

Generativity ???

A middle age client informs the nurse of an increasing weight gain. What should the nurse prepare the client for related to potential complications of the weight gain? A. Glucose level to screen for diabetes B. WBC count to screen for infection C. Hemoglobin and hematocrit to screen for anemia D. Urine specimen to screen for ketones.

Glucose level to screen for diabetes

The nurse is caring for a client at risk for aspiration. What action should the nurse take when assisting the client with the meal to prevent aspiration? A. Have the client bend the chin toward the chest when swallowing. B. Suction the clients frequently during the meal. C. Have the clients food pureed D. Place the client on the side while eating.

Have client bend the chin toward the chest when swallowing

A client has developed a large pressure wound on the right trochanter. How can the nurse best ensure this clients nutritional needs are met to assist with healing? A. Encouraging the client to drink 2L of fluid per day B. Increase fat intake to 50% of total caloric intake. C. Give vitamin and mineral supplements. D. Increase daily protein requirements.

Increase daily protein requirements

Interdependent action

Interventions that require the combined knowledge They do not require direction or an order from another health care professional. Nursing interventions are actions that are implemented in a collaboration or consultation with other health care professionals. EXAMPLE PRN pain med, there is a dr order but the nurse has to assess for pain before given/ dressing change

Independent actions

Nursing action that does not require doctor order. Use nursing judgement and asessment

The nurse is providing care for a client with presbycusis. What nursing action should the nurse perform to accommodate the clients condition? presbycusis- changes in hearing A. Speak in a clear voice while facing the client B. Provide educational brochures in large print C. Speak very loudly so that the client can hear. D. Have the walkways to the clients bed clear from obstruction

Speak in a clear voice while facing the client

A new LPN is preparing to administer medication. What action by the LPN requires the change nurse to intervene? Select all that apply A. The LPN asks the client would like to take the medication with water or juice. B. The LPN is crushing an enteric-coated aspirin. C. The LPN is hiding a pill in applesauce when the client refuses the pill. D. The LPN informs the client what medications is being administered. E. The LPN has the client swallow each pill individually.

The LPN is crushing an enteric coated aspirin The LPN is hiding a pill in applesauce when the client refuses the pill The LPN has the client swallow each pill individually

A client reports shortness of breath and wheezing and is given a nebulizer treatment with a bronchodilator. What evaluation recorded by the nurse indicates a positive outcome of the treatment? A. The client has decreased wheezing with no SOB B. The client requires O at 4 L/m by nasal cannula C. The client requires transport to a higher level of care unit. D. The client states the need for another treatment

The client has decreased wheezing with no shortness of breath

A client asks the nurse why so many wrinkles have developed on the clients face. What is the best response by the nurse? A. "This is related to problems with your liver." B. "The wrinkles are caused by stress." C. "Wrinkles are the result of a loss of elasticity." D. "The wrinkles are cause by an increase in pigmentation."

The wrinkles are a result of a loss of elasticity

Cohabitation

Unmarried individual in a commited relationship

A client is suspected of having a urinary tract infection. What specimen does the nurse obtain to determine what bacteria is present as well as what antibiotic to use? A. White blood cell count B. Urinalysis C. Urine for culture and sensitivity D. Hemoglobin

Urine culture and sensitivity

The nurse is planning for discharge of a client with diabetes. When should the nurse begin the discharge planning of this client? A. When the client is admitted to to the healthcare facility B. The day the client is to be discharged C. The day before the client is to be discharged D. Before the client is escorted out.

When the client is admitted to the healthcare system

When the client is in the establishment stage of life, what issues might the client discuss with the nurse? A. Whether or not to enter into parent hood B. Sleep patterns of their child C. Concerns about living alone since the last child left the home. D. Financial decisions regarding retirement

Whether or not enter into parenthood

Aphasia

loss of ability to understand or express speech, caused by brain damage.

Blended family

reconstruction more than 1 family; parents remarry have step children

EKG placement

white= on right snow over grass = White over green smoke over fire = black over red chocolate good for heart = brown by heart