Prep u foundation exam 1 practice

A nursing student is manually taking the client's blood pressure. Which step will demonstrate the correct way of inflating the blood pressure cuff?

Inflate the cuff to 30 mm Hg above reading where brachial pulse disappeared.

The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate?

Inform the health care provider that a written order is needed.

The nurse is performing an admission interview with a new client diagnosed with acute coronary syndrome. For the nurse to obtain information and allow the client free verbalization, which question would elicit the most information?

"Could you tell me more about how you are feeling right now?"

A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the nurse provide to the client?

"Dizziness when you change position can occur when fluid volume in the body is decreased."

A nurse is requesting to receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is most appropriate?

"It will allow for us to see the client and possibly increase client participation in care."

A home health care nurse is explaining to an emergency room nurse how nursing care in the home setting differs from that in the hospital setting. Which statement by the home health care nurse would be most appropriate?

"The client and family are in control of the setting, not the nurse."

A 47-year-old male has decided he requires more exercise, needs to eat a heart healthy diet, and avoid alcohol. This patient has determined which of the following?

A change in lifestyle influences health

A nurse is completing a health history on a client who has a hearing impairment. Which action should the nurse take first to enhance communication?

Assess how the client would like to communicate

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?

Giving false reassurance

The client responds to the nurse's questions by stating in a loud and abrupt tone, "Yes, I understand my diabetic diet and how to give my insulin." What type of message has the client sent to the nurse?

Incongruent

A nurse is assessing an adult client's blood pressure. How should the nurse estimate the client's systolic blood pressure (SBP)?

Inflate the blood pressure cuff while palpating the client's brachial or radial artery.

A nurse gives a speech on nutrition to a group of pregnant women. Within the model of the communication process, what is the speech itself known as?

Message

A nurse is calling a physician to communicate a change in the client's condition. According to the ISBARR format for handoff communication among health care personnel, which is the most appropriate way to begin the conversation?

My name is Sue Smith, RN, and I am calling regarding Mrs. Jones in room 356 at Jefferson Hospital."

A client is diagnosed with mild dementia while in the hospital. In preparing for discharge, what should the nurse discuss with the family?

Possible need for home care

The nurse is taking a rectal temperature on a client who reports feeling lightheaded during the procedure. What would be the nurse's priority action in this situation?

Remove the thermometer and assess the blood pressure and heart rate.

A nurse is performing an admission assessment with a client who does not speak the dominant language. Which action(s) can the nurse take to enhance communication? Select all that apply.

Use an electronic translator. Contact a telephone-based medical interpreter. Request assistance from an agency interpreter.

Which strategy would provide the most effective form of change of shift report?

Utilizing a reporting form and allowing time for any questions.

The nurse is preparing to measure a client's rectal temperature. Which supplies and equipment should the nurse have available before beginning the procedure? Select all that apply.

an electronic thermometer with a rectal probe disposable probe cover water-soluble lubricating gel

When assessing a client's nonverbal communication, the nurse should assess which aspect as being the most expressive?

facial expressions

A client living alone has degenerative joint disease, hypertension, and neuropathy. It is difficult for the client to bathe, and the client's blood pressure is unstable. Which type of care would this client benefit from most?

home care

A nurse gives a speech on nutrition to a group of pregnant women. Within the model of the communication process, what is the speech itself known as?

message

A nurse is maintaining a problem-oriented medical record for a client. Which component of the record describes the client's responses to what has been done and revisions to the initial plan?

progress notes

One significant change in the health care delivery system in recent years is earlier hospital discharges. What is one result of earlier hospital discharges?

Clients with high home care needs are being discharged into the community.

A 70-year-old client had a cholecystectomy 4 days ago. The client's daughter tells the nurse, "My mother seems confused today." Which question would be best for the nurse to ask to assess the client's orientation?

What is your name?

Clients demonstrating apnea have what?

temporary cessation of breathing