Prep U
The nurse is interacting with a new client who reported to the clinical facility for a health problem. Place the following statements by the nurse in the order of the nurse-client relationship. Use all options. 1. "The health care provider has recommended you to return in 1 week." 2. What health problem are you seeking help for?" 3. This medication has been prescribed by the health care provider to treat your problem." 4. Hello. I am the nurse assigned to you. My name is...."
4. Hello. I am the nurse assigned to you. My name is...." 2. What health problem are you seeking help for?" 3. This medication has been prescribed by the health care provider to treat your problem." 1. "The health care provider has recommended you to return in 1 week."
A client with cancer pain is taking morphine for pain relief. Knowing constipation is a common side effect, what would the nurse recommend to the client? A. "Increase fluids and high-fiber foods, and use a mild laxative." B. "Only take morphine when you have the most severe pain." C. "Administer an enema to yourself every third day." D. "Constipation is nothing to worry about; take your medicine."
A. "Increase fluids and high-fiber foods, and use a mild laxative."
The client is being discharged, and the nurse is reviewing the newly prescribed medications with the client. Which statement(s) will allow the nurse to evaluate the client's understanding of the medications? Select all that apply. A. "What is the reason you are taking each medication?" B. "I will provide you with written information about each medication before you leave." C. "Tell me what time of day you are to take your medications." D. "If you have questions, ask the pharmacist at the pharmacy where you obtain your medications." E. "Do you have any questions about your medications?"
A. "What is the reason you are taking each medication?" C. "Tell me what time of day you are to take your medications."
A nurse is caring for a client with orthostatic hypotension. The client is currently not taking any antihypertensive medications. Which action(s) will the nurse take to reduce the client's risk of falls? Select all that apply. A. Assist the client in applying compression stockings to lower extremities. B. Educate the client about reducing salt intake in the diet. C. Ask the client to wait 1 hour after meals to engage in physical activity. D. Encourage the client to stand up from a sitting position slowly. E. Ensure that the client is taking an adequate volume of fluids.
A. Assist the client in applying compression stockings to lower extremities. C. Ask the client to wait 1 hour after meals to engage in physical activity. D. Encourage the client to stand up from a sitting position slowly. E. Ensure that the client is taking an adequate volume of fluids.
A gerontologic nurse practitioner has a large client population with heart disease problems. This nurse practitioner is aware that heart disease is the leading cause of death in the aging adult. What is the cause of this trend? A. Blood vessels lose their elasticity with age. B. Resting heart rate decreases with age. C. The cardiac output is increased with age. D. Systolic blood pressure decreases with age.
A. Blood vessels lose their elasticity with age.
Which quality in a nurse helps the nurse to become effective in providing for a client's needs while remaining compassionately detached? A. Empathy B. Kindness C. Sympathy D. Commiseration
A. Empathy
A nurse is applying the nursing process and is in the diagnosis phase. With which activities would the nurse be involved? Select all that apply. A. Identifying indicators of potential dysfunction B. Organizing data C. Analyzing data D. Collecting subjective and objective data E. Identifying patterns
A. Identifying indicators of potential dysfunction C. Analyzing data E. Identifying patterns
Which assessment finding(s) confirms or indicates that the client is experiencing rapid-eye movement (REM) sleep? Select all that apply. A. Muscles are relaxed, but muscle tone is maintained. B. The client is unable to move. C. Deep tendon reflexes are depressed. D. The client has wet the bed. E. Blood pressure and pulse rate show wide variations and fluctuate rapidly.
A. Muscles are relaxed, but muscle tone is maintained. B. The client is unable to move. C. Deep tendon reflexes are depressed. E. Blood pressure and pulse rate show wide variations and fluctuate rapidly.
A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action? A. Remove the IV. B. Elevate the arm. C. Apply a warm compress. D. Slow the rate of IV fluids.
A. Remove the IV.
The nurse is caring for a 70-year-old client with a body mass index (BMI) of 34.8. Which risk factor should the nurse discuss with this client? A. Risk of heart disease B. Risk of infection C. Risk of low cholesterol D. Risk of osteoporosis
A. Risk of heart disease
A nurse attempts to wake a sleeping client who is scheduled for tests. The client is easily aroused from sleep. Which stage of sleep is was this client most likely experiencing? A. Stage II B. Stage IV C. Stage III D. Stage I
A. Stage II
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. A. Tenderness to palpation B. Blood pressure C. Pedal pulses D. Skin color E. Temperature of skin
A. Tenderness to palpation C. Pedal pulses D. Skin color E. Temperature of skin
The nurse has obtained subjective and objective assessment data for a client. Which client data require validation? Select all that apply. A. The client has ecchymosis on the arms and legs due to a fall. B. The client has fever and chills related to a respiratory infection. C. The client has trouble reading an informed consent document but denies needing glasses. D. The client has a blood pressure reading of 124/76 mm Hg. E. The client is unable to eat the food being served.
A. The client has ecchymosis on the arms and legs due to a fall. C. The client has trouble reading an informed consent document but denies needing glasses.
Which are examples of the Institute of Medicine's (IOM) recommendations for transforming the nursing profession? Select all that apply. A. The nurse implements a research study addressing an increase in hospitalized clients with heart failure. B. The chief nursing officer at the hospital is a non-voting board member. C. The nurse practitioner practicing in one state is moving to another state that has a scope of practice that is more limiting. D. The nurse participates in a statewide committee with other health professionals and legislators to address human trafficking. E. The associate degree nurse enrolls in a program to obtain a bachelor's degree in nursing without taking any additional courses.
A. The nurse implements a research study addressing an increase in hospitalized clients with heart failure. D. The nurse participates in a statewide committee with other health professionals and legislators to address human trafficking. E. The associate degree nurse enrolls in a program to obtain a bachelor's degree in nursing without taking any additional courses.
The nurse is choosing a collection device to collect urine from a nonambulatory male client. What would be the nurse's best choice? A. Urinal B. Specimen hat C. Bedpan D. Large urine collection bag
A. Urinal
While assessing for orthostatic hypotension, the nurse follows which step(s) when taking the blood pressure? Select all that apply. A. Use the same blood pressure cuff the whole time. B. If the client feels dizzy when standing, have the client sit on the side of the bed. C. Record measurements and note if the drop is ≥20 mm Hg systolic and ≥10 mm Hg diastolic. D. Assist client to standing position and wait 2 to 3 minutes before taking blood pressure. E. Check and record blood pressure taken while the client is in the bed.
A. Use the same blood pressure cuff the whole time. C. Record measurements and note if the drop is ≥20 mm Hg systolic and ≥10 mm Hg diastolic. D. Assist client to standing position and wait 2 to 3 minutes before taking blood pressure. E. Check and record blood pressure taken while the client is in the bed.
The nurse is preparing to administer fluid replacement to a client. Which action should the nurse take first? A. Verify the prescription for type of solution and amount of infusion. B. Check for the availability of an IV pump. C. Calculate the number of drops per minute. D. Regulate the rate of administration.
A. Verify the prescription for type of solution and amount of infusion.
A client with chronic kidney disease reports not being able to urinate for the past 24 hours. A bladder scan shows no urine in the bladder. How does the nurse document this data? A. anuria B. urinary retention C. oliguria D. nocturia
A. anuria
Which statement is an appropriate nursing concern for an 80-year-old client diagnosed with heart failure, with symptoms of edema, orthopnea, and confusion? A. excess extracellular volume related to heart failure, manifested as edema and orthopnea B. deficient fluid volume related to congestive heart failure, manifested as shortness of breath C. excess fluid volume related to loss of sodium and potassium D. heart failure related to edema
A. excess extracellular volume related to heart failure, manifested as edema and orthopnea
A client who follows a vegetarian diet should include which foods to maintain a healthy diet? A. legumes and vegetables B. red meat C. chocolate and wine D. processed white bread
A. legumes and vegetables
A nurse is providing education to an older adult client concerning ways to prevent constipation. Which diet choices would support that the education was successful? Select all that apply. A. prune juice with breakfast B. hot tea with meals C. ice cream with lunch and dinner D. diet soda with lemon E. a turkey sandwich with whole-grain bread
A. prune juice with breakfast B. hot tea with meals E. a turkey sandwich with whole-grain bread
The primary extracellular electrolytes are: A. sodium, chloride, and bicarbonate. B. phosphorous, calcium, and phosphate. C. potassium, phosphate, and sulfate. D. magnesium, sulfate, and carbon.
A. sodium, chloride, and bicarbonate.
The nurse is conducting a community assessment that focuses on Healthy People 2030 health promotion guidelines. What would be important for the nurse to include when performing the community assessment to meet the Healthy People 2030 goals? Select all that apply. A. violent crime rate B. number of health clinics C. number of individuals living in a household D. number of homes with air conditioning E. sudden infant death syndrome (SIDS) rate
A. violent crime rate B. number of health clinics E. sudden infant death syndrome (SIDS) rate
The nurse is caring for a client diagnosed with dementia. Which behaviors would the nurse most likely assess? Select all that apply. A. wandering B. asking questions repeatedly C. stable mood D. socially inappropriate behavior E. irritability
A. wandering B. asking questions repeatedly D. socially inappropriate behavior E. irritability
A client, who has just been diagnosed with a chronic condition, asks the nurse what a "chronic condition" means. What would be the nurse's best response? A. "Chronic conditions involve disabilities that require hospitalization." B. "Chronic conditions usually come on slowly and may have periods of remission and exacerbation." C. "Chronic conditions are diseases that come and go." D. "Chronic conditions require short-term management in extended-care facilities."
B. "Chronic conditions usually come on slowly and may have periods of remission and exacerbation."
A client admitted to the hospital asks the nurse whether it would be acceptable for the client to bring food from home to eat that better meets the client's cultural preferences. What is the nurse's best response? A. "I'm sorry, but you are not permitted to bring food from home." B. "Food from home is fine as long as it does not violate hospital policy or contradict the prescribed diet." C. "Food from home has too much fat and salt and should be avoided." D. "No, you must learn to adjust to the food that is provided."
B. "Food from home is fine as long as it does not violate hospital policy or contradict the prescribed diet."
The nurse is educating a client about restless leg syndrome. What statement made by the client indicates that further education regarding restless leg syndrome is required? A. "My heating pad will decrease the tingling in my legs." B. "I will try to lose weight so I can sleep better at night." C. "I will eliminate the use of tobacco products and caffeine." D. "I won't drink any wine with dinner or in the evening."
B. "I will try to lose weight so I can sleep better at night."
While interviewing a client who has come to the clinic, the client says to the nurse, "I've seen all these apps that are available to monitor my health, but I'm not sure which one would be best. Do you have any suggestions?" Which response by the nurse would be most appropriate? A. "Most of the apps available are really good. Just pick one that looks interesting." B. "It's important that the app is high quality. Be sure to make sure the app is credible." C. "Apps are really just a fad right now. There's bound to be something new coming." D. "Apps that are free are usually the best ones to choose."
B. "It's important that the app is high quality. Be sure to make sure the app is credible."
A client states that urinary incontinence has become a problem and asks the nurse how to help control or alleviate this problem. Which statement by the nurse would be accurate? A. "It is best to have a Foley catheter inserted to prevent incontinence." B. "Performing Kegel exercises can help with muscle strengthening." C. "Coffee and diet sodas are not factors with being incontinent of urine." D. "You need to decrease your daily fluid intake to help with this."
B. "Performing Kegel exercises can help with muscle strengthening."
The nurse is caring for a client who reports constipation and is presently in the bathroom attempting to have a bowel movement. The client presses the call bell and tells the nurse that about feeling dizzy. What education should the nurse provide the client about this condition? A. "There may be an issue with your colon that is causing these type of symptoms. It is unusual to feel dizzy while having a bowel movement." B. "This occurs when bearing down and decreasing blood flow to the heart; when you stop, the blood flow will return in a larger amount." C. "This happens when you bear down causing an increase in blood volume to the heart and resulting in your heart rate becoming too rapid." D. "This is an indicator of heart disease and we should do an electrocardiogram to be sure that it has not caused damage to the heart."
B. "This occurs when bearing down and decreasing blood flow to the heart; when you stop, the blood flow will return in a larger amount."
A nurse is moving to another state and will be working at an acute care facility. Prior to beginning practice, what actions should the nurse take to be compliant with state guidelines for nursing practice? Select all that apply. A. Visit the state board of nursing offices B. Access educational resources related to nursing practice in another state C. Locate the state nursing practice acts D. Define the legal requirements and titles for registered nurses (RNs) and licensed practical nurses (LPNs) E. Research the laws and regulations that govern nursing practice in the new state F. Let the present state board of nursing know that the nurse is leaving the state
B. Access educational resources related to nursing practice in another state C. Locate the state nursing practice acts D. Define the legal requirements and titles for registered nurses (RNs) and licensed practical nurses (LPNs) E. Research the laws and regulations that govern nursing practice in the new state
A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client? A. Eat crackers and bread. B. Avoid salty or excessively sweet fluids. C. Use regular gum and hard candy. D. Use an alcohol-based mouthwash to moisten your mouth.
B. Avoid salty or excessively sweet fluids.
The nurse is preparing a care plan for a client recently diagnosed with obstructive sleep apnea. The client reports daytime sleepiness, fatigue, and excessive snoring that "wakes me up." What nursing diagnosis would be appropriate for this client? A. Disturbed Sleep Pattern as evidenced by complaints of daytime sleepiness B. Disturbed Sleep Pattern related to periods of apnea as evidenced by excessive snoring C. Disturbed Sleep Pattern related to obstructive sleep apnea as evidenced by excessive snoring D. Disturbed Sleep Pattern related to obstructive sleep apnea
B. Disturbed Sleep Pattern related to periods of apnea as evidenced by excessive snoring
The nurse is documenting a teaching session with a client. Which nursing documentation is the most appropriate and detailed? A. Education provided. Spouse present during session. Client and spouse state understanding and provided return demonstration of skill. B. Family requested education on turning client. Explanation of use of draw sheet and body mechanics provided. Family coached through turning and repositioning client. Members state confidence and understanding. C. Written material about diabetes mellitus reviewed. Observed demonstration of finger stick and use of glucometer. Will return demonstration with next scheduled glucose monitoring. D. Taught about need for INR monitoring after initiating warfarin therapy. Client's meter used for demonstration and return demonstration. Remediation provided twice to place strip in meter correctly. Questions answered.
B. Family requested education on turning client. Explanation of use of draw sheet and body mechanics provided. Family coached through turning and repositioning client. Members state confidence and understanding.
An older adult woman has been in the hospital for more than 1 week. While assessing her intravenous catheter port, the nurse finds a staph infection, which has developed in the past day or so. This infection is an example of which type of infection? A. Sexually transmitted infection B. Healthcare-associated infection C. Respiratory infection D. Droplet infection
B. Healthcare-associated infection
What assessment technique would the nurse use to assess a client's chest for color, shape, or contour? A. Percussion B. Inspection C. Auscultation D. Palpation
B. Inspection
A nurse is collecting a stool specimen from a client. Which measures are appropriate for this procedure? Select all that apply. A. Generally, 2 inches of formed stool or 20 to 30 mL of liquid stool is sufficient for a stool specimen. B. Medical aseptic techniques are always followed. C. Handwashing is performed before and after glove use when handling a stool specimen. D. The client should be instructed not to place toilet tissue in the bedpan or specimen container. E. The client should be asked to defecate into a clean bedpan or toilet bowl, depending on the nature of the study. F. The client should be asked to void first because the lab study may be inaccurate if the stool contains urine.
B. Medical aseptic techniques are always followed. C. Handwashing is performed before and after glove use when handling a stool specimen. D. The client should be instructed not to place toilet tissue in the bedpan or specimen container. F. The client should be asked to void first because the lab study may be inaccurate if the stool contains urine.
A nurse in a wellness center is presenting a class on integrating holistic therapies with traditional health care. The nurse talks about the trend in health care to treat each client in a manner that reconnects the total being. Which would best be considered a holistic approach to health? A. Financial success and post-secondary education B. Physical, emotional, and spiritual well-being C. Healthy work environment D. Emotional and sexual contact
B. Physical, emotional, and spiritual well-being
A client is being discharged to home following a diagnosis of lung carcinoma and subsequent treatment with pneumectomy surgery. The client has a prescription for continuous home oxygen. Which measure(s) will the nurse include in a teaching plan aimed at increasing oxygen-related home safety? Select all that apply. A. Ensure tanks are stored at least 3 feet away from fire sources. B. Post a "no smoking" sign in a conspicious area. C. Ensure concentrators are stored flush against a wall. D. Avoiding storing oxygen in cooler areas of the home. E. Use caution with gas or electrical appliances. F. Keep burnable solids away from portable concentrators.
B. Post a "no smoking" sign in a conspicious area. E. Use caution with gas or electrical appliances.
The nurse is preparing to administer a bolus of furosemide 0.8 mg to a client with congestive heart failure and kidney disease. Which right of drug administration would the nurse question and confirm in this client? A. Right dose B. Right drug C. Right client D. Right route
B. Right drug
Which accurately identify the characteristics of effective client goals represented in the acronym SMART? Select all that apply. A. S = supportive B. S = specific C. R = realistic D. A = accurate E. T = timebound F. M = measurable
B. S = specific F. M = measurable C. R = realistic E. T = timebound
The nurse is conducting a home assessment and suggests that the client's family remove scatter rugs from the home and increase the lighting. Which basic human need is being addressed by the nurse's suggestions? A. Physiologic B. Safety and security C. Self-actualization D. Self-esteem
B. Safety and security
A nurse is collecting data from a home care client. In addition to information about the client's health status, which is another critical observation the nurse should make? A. Friendliness of the client and family B. Safety of the immediate environment C. Number of rooms in the house D. Frequency of home visits to be made
B. Safety of the immediate environment
A 38-year-old client is in an outpatient clinic reporting chronic back pain. As the nurse reviews the chart, the nurse notices that the client has required escalating doses of hydromorphone to treat this pain. The client tells the nurse that "the old dose just doesn't work anymore." What term best describes this client's situation? A. Addiction B. Tolerance C. Withdrawal D. Whining
B. Tolerance
After a client falls out of bed, the nurse completes: A. a progress note stating event report was completed. B. a safety event report (incident report). C. a malpractice report. D. a telephone call to hospital's attorney.
B. a safety event report (incident report).
A nurse is providing an in-service program for a group of nurses who work with the older adult population. After describing the older adult population's risk for abuse and neglect, the nurse determines that the education was successful when the group identifies a vulnerable adult as having which characteristic? Select all that apply. A. adult without a legal guardian B. adult 60 years or older lacking self-care ability C. adult in a long-term care facility D. adult receiving provider services while living in his own home E. adult with disability
B. adult 60 years or older lacking self-care ability C. adult in a long-term care facility D. adult receiving provider services while living in his own home E. adult with disability
Nursing is described in various ways. The focus of all nursing interventions should involve which factor(s)? Select all that apply. A. curing the illness in individuals B. human experience and responses of individuals, families, and groups C. birth, health, illness, and death of individuals D. use of evidence-based practice to ensure the best care E. pyschosocial dimension of the client
B. human experience and responses of individuals, families, and groups C. birth, health, illness, and death of individuals D. use of evidence-based practice to ensure the best care E. pyschosocial dimension of the client
During an orientation class for new RN graduates, the nurse educator identifies which conditions as potential risks for clients to experience sleep pattern disturbance? Select all that apply. A. type 1 diabetes mellitus B. stroke C. depression D. glaucoma E. substance use F. constipation
B. stroke C. depression E. substance use F. constipation
The nurse conducting an in-service on hand hygiene determines that additional education is needed when a participant states: A. "I will wash my hands before touching a client." B. "I can wash my hands before a clean procedure." C. "I do not need to wash my hands if I am using gloves." D. "If I am able, I will wash my hands after touching the client's surroundings."
C. "I do not need to wash my hands if I am using gloves."
The nurse is administering the first dose of an intravenous infusion of an antibiotic. Which statement made by the client is cause for concern? A. "I feel like I need to urinate." B. "I feel hungry." C. "I feel like my back and arms are itching." D. "I feel very tired."
C. "I feel like my back and arms are itching."
A client reports to a primary care health care provider with aggravated chest pain. The health care provider orders a stress test. The client tells the nurse that the client does not want to take the test and would prefer instead to continue taking medication a little longer. Understanding that the client is anxious, what is the most appropriate response by the nurse? A. "Don't you want to improve your health?" B. "Most people tolerate the procedure quite well." C. "Tell me more about how you are feeling." D. "Emergency equipment is always kept ready during stress tests."
C. "Tell me more about how you are feeling."
The nurse is interviewing a client and is focusing on avoiding comments and questions that will impede communication. Which sentence demonstrates the appropriate use of communication techniques? A. "Why do you feel that way about your cancer diagnosis?" B. "Do you have any additional questions for me?" C. "When did you first notice the rash on your leg?" D. "Have you ever heard the saying 'no pain no gain?'"
C. "When did you first notice the rash on your leg?"
Which nursing actions would the nurse perform when assisting clients with passive ROM exercises? Select all that apply A. Begin ROM exercises at the client's head and move down one side of the body at a time. B. Perform each exercise 10 to 15 times. C. Adjust the bed to the flat position or as low as the client can tolerate. D. Move each joint in a smooth, rhythmic manner. E. Use a flat palm to support joints during ROM exercises. F. Raise the bed to the highest position.
C. Adjust the bed to the flat position or as low as the client can tolerate. A. Begin ROM exercises at the client's head and move down one side of the body at a time. D. Move each joint in a smooth, rhythmic manner.
Which task may be safely delegated to unlicensed assistive personnel (UAP)? A. Administering tube feeding to a client who has had a stroke B. Inserting a nasogastric (NG) tube into a client with persistent nausea C. Assisting a client to eat D. Removing a client's NG tube after surgery
C. Assisting a client to eat
Nurses use approved NANDA-I nursing diagnoses when writing diagnoses for clients. Which diagnoses represent "Domain 1: Health Promotion" as established by NANDA-I? Select all that apply. A. Impaired Environmental Interpretation Syndrome B. Readiness for Enhanced Coping C. Decreased Diversional Activity Engagement D. Sedentary Lifestyle E. Ineffective Health Management F. Risk for Disuse Syndrome
C. Decreased Diversional Activity Engagement D. Sedentary Lifestyle E. Ineffective Health Management
An older adult client with mild hypothermia has been admitted to the health care facility. Which intervention will the nurse use to promote comfort and sleep for the older adult client? A. Use a bright light at night for safety. B. Keep an attendant with the client. C. Ensure that the environment is warmer. D. Raise the side rails of the bed.
C. Ensure that the environment is warmer.
A nurse is caring for a client who is visually impaired. Which action is a recommended guideline for communication with this client? A. Speak in a louder voice to make up for the client's inability to perceive visual cues. B. Keep communication simple and concrete. C. Explain the reason for touching the client before doing so. D. Ease into the room without announcing your presence until you can touch the client.
C. Explain the reason for touching the client before doing so.
A nurse who is preparing to administer an injection to the client states, "This injection will not be painful." The nurse has used which communication technique? A. Encouraging elaboration B. Giving information C. Giving false reassurance D. Seeking clarification
C. Giving false reassurance
What is an advantage of using an external condom catheter for a male client who has frequent episodes of urinary incontinence? A. The client can apply it himself with minimal supervision. B. It can be left in place for a long period of time. C. It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters. D. A sterile urine specimen can be obtained from the drainage bag tubing.
C. It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters.
A family presents to the emergency room with a 4-year-old child who is crying and reporting that the skin on the legs are itching and hurting. The parent explains that they were out walking in the woods when the child went running off the path and into some tall weeds. Which finding(s)s should the nurse prioritize in this assessment? Select all that apply. A. 4-year-old at 85 percentile of growth and development B. Respirations 18 breath/min and regular C. Redness and blisters forming on both legs D. Stating "My legs feel like they are burning" E. Crying and trying to scratch legs due to itching
C. Redness and blisters forming on both legs D. Stating "My legs feel like they are burning" E. Crying and trying to scratch legs due to itching
When reviewing data collection on a client with constipation, which factor identified by the nurse might suggest the causative factor? A. The client drinks 8 glasses of fluid daily. B. The client eats five to six small meals per day. C. The client takes bisacodyl every day. D. The client traveled to South America two weeks ago.
C. The client takes bisacodyl every day.
A nurse is preparing to measure a client's urine output. Which interventions would be of highest priority? A. Noting the color and clarity of the urine B. Measuring the urine container at eye level C. Wearing gloves when handling the urine D. Using an appropriate measuring container
C. Wearing gloves when handling the urine
What is the term used to describe a pharmaceutical agent that relieves pain? A. antihistamine B. antibiotic C. analgesic D. antacid
C. analgesic
A nurse is caring for a client who reports chest pain. Which test levels would indicate whether the client is at risk for cardiac and vascular disease? A. calories in each food intake B. unsaturated fats C. cholesterol D. balanced proteins
C. cholesterol
A client's son is named to make decisions for his mother in the event she cannot speak for herself. This is an example of a(an): A. exemplary representative. B. significant power. C. durable power of attorney. D. advance estate director.
C. durable power of attorney.
An older adult is admitted to the health care facility with a diagnosis of depression. The nurse would be especially alert for: A. sleep problems. B. lack of initiative. C. suicidal thoughts. D. poor cognitive performance.
C. suicidal thoughts.
Which question or statement would be appropriate for eliciting further information when conducting a health history interview? A. "Why didn't you go to your health care provider when you began to have this pain?" B. "If I were you, I would not wait to get help next time." C."Tell me more about what caused your pain." D. "Are you feeling better now than you did during the night?"
C."Tell me more about what caused your pain."
Which nursing assessment guideline is most accurate? A. "Assess your client after receiving the nursing report and again before giving a report to the next shift of nurses." B. "Collect assessment data prior to the health care provider rounding on the unit." C. "Assess your client at least hourly if the client's vital signs are unstable, and every 2 hours if the vital signs are stable." D. "Collect assessment data about the client continuously."
D. "Collect assessment data about the client continuously."
A nurse is reviewing the health history and physical assessment findings for a client who is having respiratory problems. Which client statement from the health history would be a cue to a nursing diagnosis for this problem? A. "My skin is so dry, I just can't keep from scratching." B. "I often have diarrhea after I eat spicy foods." C. "I just feel so bad about myself these days." D. "I get out of breath when I walk a few steps."
D. "I get out of breath when I walk a few steps."
Family members of a dying client are in the room with their loved one. As the client nears death, what should the nurse tell the family? A. "Only one family member at a time can stay in the room." B. "I will have to get an order for you to stay now." C. "Please leave the room now. It is time to let go." D. "Please stay with your loved one and talk to him."
D. "Please stay with your loved one and talk to him."
Which assessment data cue does the nurse recognize as subjective data? A. Wheezing throughout lung fields B. Bilateral pedal edema 2+ C. Pupils equal and accommodate and react to light D. A pain rating of 7
D. A pain rating of 7
A nurse is interviewing a client who has come to the clinic for a follow-up visit. The nurse notices the client does not make eye contact and speaks while looking down. How should the nurse respond? A. Touch the client's hand and say, "You seem upset, is there something bothering you?" B. Sit silently until the client looks up and makes eye contact. C. Stop the interview and ask, "How are you feeling?" D. Assume a position at eye level with the client and continue with the interview.
D. Assume a position at eye level with the client and continue with the interview.
A nurse is caring for an older adult client with arthritis. Which action is the priority for the nurse when conducting the health education for the client? A. Provide an environment that promotes learning. B. Identify how long the education session will last. C. Divide information into manageable amounts. D. Find out what the client wants to know.
D. Find out what the client wants to know.
The nurse is caring for a client with malnutrition due to protein deficiency. Which food should be included in this client's diet? A. Green vegetables B. Citrus fruits C. Roots D. Meats
D. Meats
The nurse is assessing a client with vascular dementia. As a result of this cognitive deficit, the client is unable to provide many of the data that are required. How should the nurse best proceed with this assessment? A. Perform the assessment in several short episodes rather than at one sitting. B. Limit the assessment to objective data. C. Obtain the client's records from admissions to other institutions. D. Supplement the client's information by speaking with family or friends.
D. Supplement the client's information by speaking with family or friends.
The nurse is assessing a client for pain and suspects that the client's culture may be affecting the pain response. What nonverbal indicator of pain would the nurse expect to observe? A. The client is laughing loudly with family. B. The client is praying with members of the clergy. C. The client requests to take a walk outside. D. The client is holding pressure on the abdomen when speaking.
D. The client is holding pressure on the abdomen when speaking.
A client is underweight. Which is the best goal for the client and nurse to construct and mutually agree to implement? A. To gain 5 lb (2.25 kg) per 1 day B. To eat dessert after every meal C. To maintain a clear liquid diet D. To consume 80% of the diet tray for each meal
D. To consume 80% of the diet tray for each meal
The nurse assesses that a client is shivering. Which intervention is most appropriate to prevent further stress on the body? A. applying a cooling blanket B. promoting good ventilation by using an electric fan C. providing a warm sponge bath D. applying a blanket
D. applying a blanket
The nurse learns during the assessment of a client that the client has difficulty falling asleep, wakes up early, and does not feel refreshed in the morning. This client is most likely experiencing: A. ineffective coping. B. increased sleep. C. activity intolerance. D. disturbed sleep pattern.
D. disturbed sleep pattern.
The nurse observes the client for signs of stage I pressure injury development, which most likely will include which finding? A. a shallow open injury B. exposed bone with eschar C. visible subcutaneous fat D. nonblanchable redness
D. nonblanchable redness
Assessment of a 70-year-old client reveals the following: Reports of napping occasionally during the day Problems with driving at night Edema of the feet with pitting Reports of dry mouth Awakening 2 to 3 times to void at night Burning on urination Which finding(s) does the nurse identify as a concern? Select all that apply. A. nighttime driving problems B. daytime napping C. nighttime awakening to void D. painful urination E. pitting edema of the feet F. dry mouth
D. painful urination E. pitting edema of the feet
Based on an understanding of the cognitive changes that normally occur with aging, what might the nurse expect a newly hospitalized older adult to do? A. withdraw from strangers B. interrupt with frequent questions C. talk rapidly but be confused D. take longer to respond and react
D. take longer to respond and react
The nurse is caring for a client who is ordered to be in the Fowler position. When assessing the client's position in bed, the nurse will adjust the client in bed if what is observed? Select all that apply. A. There is a rolled towel beside the client's hips. B. The client's forearms are supported on pillows. C. The knee gatch on the bed is engaged. D. There is a large pillow under the client's head. E. The client's foot is in the plantar flexion position.
E. The client's foot is in the plantar flexion position. C. The knee gatch on the bed is engaged. D. There is a large pillow under the client's head.
After identifying data relevant to the client's agitation, the nurse identifies the client condition(s) most likely causing the client's agitation. Which client condition(s) are most likely the cause of the client's agitation? Select all that apply. A. hypoxia B. tube feeding intolerance C. Clostridioides difficile D. IV infiltration E. medication reaction F. sensory overload G. dementia
F. sensory overload
