Prep U mastery level quizzes
Which documentation example best reflects the complexity of client teaching by the nurse?
"Client and spouse taught how to use phone app to count carbohydrates; client return demonstrated carb counting for a hypothetical meal."
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."
The nurse is teaching a nursing student about caring for a client with dentures. Which education will the nurse provide?
"Hold dentures over a plastic basin or towel when cleaning them."
A nurse is caring for a client with limited physical mobility. The nurse has completed bathing the client and a student nurse asks, "Why are you making a trochanter roll?" After reviewing the image, which response by the nurse to the student would be most accurate?
"I am placing the new linens under the rolled, soiled lines to avoid contamination."
The nurse is taking the apical pulse of a 6-month-old infant. Upon completion, the nurse tells the parent the baby's pulse is 140 beats per minute. The parent is concerned, stating, "That seems kind of high!" The nurse responds:
"I know it seems fast, but normal infant heart rates are 100-160 beats per minute."
A nurse is asking a colleague about a situation. Which statement demonstrates assertive communication?
"I think there is a better way to handle this."
A nurse is assisting a client with his bed bath. The client states, "I can do it myself." Which is the nurse's best response?
"I will set up your bath for you. I will come back and help you with your bath."
A nurse is evaluating the effectiveness of health promotion teaching related to hygiene at a community workshop. Which statements by one of the participants requires further teaching to ensure understanding? Select all that apply.
"It is important to brush your teeth regularly but flossing is not necessary since it can damage the gums." "Hygiene does not contribute to my well-being so I can choose to not perform hygiene." "Hygiene measures have no affect on skin."
The nurse is assisting an older adult client with dementia in getting dressed after morning care. Which statement would be most beneficial to the client?
"Put your arm in this sleeve."
The nurse has provided education to a client about home care for an open surgical wound on the lower left extremity. When evaluating learning through the cognitive domain, what statement by the nurse would be appropriate?
"Tell me about what signs of infection you will report to the health care provider."
Which statement made by the nurse indicates data that would be documented as part of an objective assessment?
"The client's right leg is cold to the touch, from the knee to the foot."
Which statement made by the client, regarding flat patches of brown skin on the face, demonstrates understanding?
"These brown spots are senile lentigines and are common when you get older."
A 71-year-old client is concerned about brown patches of skin on their face and forearm. What is the appropriate nursing statement?
"Those are senile lentigines and are common in older adults."
A student nurse asks the nurse what trochanter rolls are used for when providing client care. What is the appropriate nursing response?
"To prevent the legs from rotating outward."
A nurse is taking care of a client with schizophrenia who only recently started taking her medications again. When she is off of her medications she often forgets to bathe and does not wear clothing that is appropriate for the weather. In order to assess her normal pattern of self-care while on her medications, which question would be most appropriate for the nurse to ask?
"What are your expectations about bathing at this time?"
A nurse is engaged in the most basic level of reflection. Which question would the nurse most likely ask?
"What happened?"
The nurse is teaching an 80-year-old client how to instill eye drops for glaucoma. The client's daughter asks, "How do you know that my mother understands what to do?" What is the appropriate nursing response?
"When 15 minutes have passed, I will ask your mother to show me how to instill the drops."
During an admission intake assessment, a nurse uses open-ended questions to gather information. An example of an open-ended question is:
"Why did your physician send you here to be admitted?"
The home care nurse notices that the client only has a glass thermometer. What is the bestresponse by the nurse?
"Would you consider using a digital thermometer?"
The nurse is visiting a client who was released from inpatient rehabilitation 6 weeks ago after a 5-month recovery from a motor vehicle accident that left the client immobile. As the nurse enters the home, the client braces hands on the arms of a chair to rise and uses crutches to walk across the room. What is the best response by the nurse?
"You have made an amazing recovery."
A client has undergone foot surgery and will use crutches in the short term. Which teaching point should the nurse provide to the client?
"Your elbows will be slightly bent when you are using your crutches."
Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period?
1700
A nurse is assessing the respiratory rate of a sleeping infant. What would the nurse document as a normal finding?
30 to 60 breaths/min
The nurse is caring for four clients. For which client is a sitz bath most appropriate?
51-year old with hemorrhoids
A nurse is counseling several clients for depression. Four of them do not seem to be improving, which leads the nurse to suggest a referral to a psychiatric nurse practitioner. Which of these clients would be most likely to attend the scheduled appointment?
A 28-year-old female who works nights, is willing to try, and asks about insurance coverage of the appointment
Nurses use social media to share ideas, develop professional connections, access educational offerings and forums, receive support, and investigate evidence-based practices. Which is an example of the proper use of social media by a nurse?
A nurse uses a disclaimer to verify that any views the nurse expresses on Facebook are the nurse's alone and not the employer's.
Which nursing student would most likely be held liable for negligence?
A nursing student administers medication to a resident while working as an unlicensed assistive personnel (UAP) at a local nursing home.
A client is in a persistent vegetative state. The client has no immediate family and is a ward of the state. Under these circumstances, who will speak on this client's behalf?
A surrogate decision maker
The nurse observes a client independently move all the joints through their normal motions. Which range of motion has the client demonstrated?
Active range of motion
The nurse is developing a plan of care for a client with a fractured femur who is in traction and will be restricted to bed for some time. Which domain should the nurse consider when developing a nursing diagnosis based on this client's musculoskeletal health problems?
Activity and rest
The nursing student learns in Fundamentals that the primary purpose for using proper body mechanics is for which reason?
Acts to prevent injury to the client and/or nurse
The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement?
Adduction
The nurse is caring for an underweight client diagnosed with a new food allergy to wheat, rye, and oats and with a nursing diagnosis of Imbalanced Nutrition: less than body requirements. What is the most appropriate intervention for this client?
Administer a 2,500-calorie (10,460-kJ) diet, excluding wheat, rye, and oats
Which action constitutes battery?
An older adult client refuses an intramuscular injection, but the nurse administers it.
The nurse is caring for a client who presents with polydipsia, polyphagia, and polyuria. The client's laboratory test results reveal an increased HgbA1C level, which could indicate increased blood glucose levels. What is the next step for the nurse to take based on the nursing process?
Analyze the data and create an individualized nursing diagnosis.
A nurse is educating a pregnant client in preterm labor on the use of the client's home monitoring equipment and medications. Which factor could impede the client's ability to learn?
Anxiety
The nurse is attempting to assess a client's radial pulse. The pulse is weak, irregular and unable to be counted. What action would the nurse take next?
Assess the apical pulse.
An Indian client is admitted to a facility for treatment of pneumonia. Since admission, she has been unwilling to participate in care offered by the nursing staff but is too weak to provide her own care. The nurse is planning care for this client with a diagnosis of Bathing/Hygiene: Self-Care Deficit. What would the priority nursing intervention be?
Assess the client's cultural views regarding hygiene and self-care.
The nurse must instruct a 35-year-old client with Down syndrome about the use of an albuterol rescue inhaler. Which documentation demonstrates appropriate individualization of the education plan for this client?
Assessed the client's understanding of illness; assessed motor skills and developmental stage; provided clarification
A nurse is conducting focused data collection and recognizes the existence of cues. The nurse is most likely involved in which phase of the nursing process?
Assessment
Put the phases of the nursing process in the correct order.
Assessment Diagnosis Planning Implementation Evaluation
The registered nurse is collaborating in the care of several medical clients. Which tasks may the nurse safely delegate to unlicensed assistive personnel (UAP)? Select all that apply.
Assessment of a client's axillary temperature Assessment of a client's radial pulse
The nurse is preparing to measure an adult's orthostatic blood pressure. Place the following steps of the procedure in the correct order. Use all options.
Assist the client into a supine position. Wait 3 to 10 minutes, then measure the client's blood pressure. Assist the client to the sitting position with legs dangling. Wait 1 to 3 minutes, then measure the client's blood pressure. Assist the client to a standing position. Wait 2 to 3 minutes, then measure the client's blood pressure.
A nurse is caring for a postoperative client 1 day after a total abdominal hysterectomy. Which nursing intervention best demonstrates caring in this situation?
Assisting the client to sit up in a chair
A nurse attempts to count the respiratory rate of a client via inspection and finds that the client is breathing at such a shallow rate that it cannot be counted. What is an alternative method of determining the respiratory rate for this client?
Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2.
A nurse is completing a health history with a newly admitted client. During the interview, the client presents with an angry affect and states, "If my doctor did a good job, I would not be here right now!" What is the nurse's best response?
Be silent and allow the client to continue speaking when ready.
While assessing vital signs of a client with a head injury and increased intracranial pressure (IICP), a nurse notes that the client's respiratory rate is 8 breaths/minute. How will the nurse interpret this finding?
Bradypnea is a response to IICP.
Which peripheral pulse site is generally used in emergency situations?
Carotid
A nurse is preparing to help a client with a skin infection have a tub bath. In which way can the nurse ensure the client's safety?
Check that the bathroom has a nonskid floor.
Which activity is the clearest example of the evaluation step in the nursing process?
Checking the client's blood pressure 30 minutes after administering captopril
A client is lying on her back with her arms at her side and knees supported with a pillow. What nursing documentation is most appropriate for this client?
Client is in supine position with arms in functional position and pillow support under the knees.
A client reads the nutritional chart and follows it accurately. The nurse also notes that the client understands the need for a balanced diet and its relationship with a quick recovery. In which domain is the client demonstrating successful learning?
Cognitive
The nurse has educated the client on the pathophysiology of osteoarthritis and degenerative joint disease. This type of teaching best illustrates which learning theory?
Cognitive learning theory
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.
Which group of terms best defines assessing in the nursing process?
Collection, validation, communication of client data
While performing an assessment, the nurse recognizes that the nurse's own personal biases may be interfering with the collection of data. What step should the nurse take to ensure that the information is factual and accurate?
Consult with another nurse for that colleague's description of the assessment or observations
A nurse is working with an older adult client, educating the client on how to ambulate with the aid of a walker. The nurse notes that the client appears to lack the motivation to learn how to use the device. The client states, "I'm just too old to learn." What would be most appropriate for the nurse to do to motivate this client?
Describe how the walker can improve the client's quality of life.
A novice nurse is engaging in reflection. The nurse would most likely be involved in which action?
Describing the events
The nurse is coaching a client who stated a desire to stop smoking without medication. At several sessions to assess the client's success with agreed-upon interventions, the client reports barriers to each action and continues to smoke. What is the best action of the nurse?
Discuss the client's case with a colleague.
When assessing a client's respiratory rate, the nurse should take which action?
Do it immediately after the pulse assessment so the client is unaware of it.
A client reports hearing voices in the head that tell the client to do bad things. When the nurse enters the client's room, the client is talking out loud to someone but there is nobody in the room. How should the nurse record this assessment?
Document this assessment based on the client's behaviors.
Which statement describes diastolic blood pressure?
During ventricular relaxation, blood pressure is due to elastic recoil of the vessels.
The nurse is visiting a hospice client in the client's home. The client is explaining difficulties with a home infusion pump. By making statements such as "I see" and "go on" during the conversation, the nurse is using which therapeutic nurse-client communication technique?
Encouraging elaboration
Once the nurse has administered pain medication, it is the nurse's responsibility to determine its effect and any other results. When accomplishing this follow-up with the client, the nurse is in which step of the nursing process?
Evaluation
The nurse is in the evaluation phase of the nursing process when developing the plan of care for a client. What should the nurse determine this phase will include? Select all that apply
Evaluation is the last part of the nursing process. Evaluations should be documented daily in the client's record. The evaluation is used to determine decisions about terminating, continuing, or modifying the plan of care.
A client with a history of benign prostatic hyperplasia presents to the emergency room with reports of urinary retention. The nurse collects data related to the client's voiding patterns, weight gain, fluid intake, urine volume in the bladder, and level of suprapubic discomfort. What type of assessment is the nurse performing?
Focused
A client who has been lying prone reports shortness of breath and a sensation of choking. Into which position will the nurse place the client?
Fowler's
A nurse working on a busy medical-surigcal unit does not take the vital signs of client who is preparing for discharge but instead documents the same vital signs obtained for this client earlier in the morning. For which tort would the nurse be potentially liable?
Fraud
A client with iron deficiency has a common complication that results in an inflammation of the tongue. What is the term used for this condition?
Glossitis
As the nurse enters the room to teach the client about self-care at home, the client states, "I am glad you are here. I need some pain medicine. I can't stand it anymore." What is the best action of the nurse?
Have the client rate pain level, and reschedule the teaching session.
The spouse of a client who has recently been diagnosed with early-stage Alzheimer's disease asks the nurse to recommend websites that may supplement the spouse's learning about this diagnosis. How should the nurse respond to the spouse's request?
Identify and recommend some credible websites appropriate to the spouse's learning needs.
A nurse receives an order to apply graduated compression stockings for a client at risk for venous thromboembolism. How should the nurse apply the stockings?
If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings.
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 artery.
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.
Which statement best conveys the role of intuition in nurses' problem solving?
Intuition can be a clinically useful adjunct to logical problem solving.
Which is a characteristic of person-centered care?
It is a framework for providing care.
Which statement regarding critical thinking in nursing is true?
It is a systematic way of thinking.
The nurse is educating an adolescent on how to treat acne. What would the nurse include as an education point?
Keep hair off the face and wash hair daily.
A new mother has brought her infant into the pediatric clinic. The infant has an excoriation on the buttocks. What should the nurse instruct the mother?
Keep the diaper and buttocks clean and dry and apply zinc oxide.
The nurse is caring for a client who has been diagnosed with pediculosis. What intervention will the nurse provide?
Launder gowns, linens, and towels separate from other clients' items.
The nurse is caring for a client who has a large furuncle in the right axillae. What education will the nurse provide?
Launder personal bath items in hot water and bleach.
What is the most appropriate teaching strategy for the nurse to use for a 1-hour presentation on the prevention of osteoporosis to a group of 30 college-age women?
Lecture/discussion
The nurse is preparing to assess the peripheral pulse of an adult client. Which action is correct?
Lightly compress the client's radial artery using the first, second, and third fingers.
The nurse is assessing the apical pulse of a client using auscultation. What action would the nurse perform after placing the diaphragm over the apex of the heart?
Listen for heart sounds.
A nurse is reading a journal article about providing individualized care. Which aspect would the nurse most likely read about as the almost universally accepted method for providing nursing care?
Nursing process
Which nursing skill uses all five senses?
Observation
Which nursing action is applicable to the psychomotor domain of learning when conducting a teaching session for breastfeeding mothers?
Observing a mother expressing the breast milk
A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure?
Over the client's thigh
The nurse needs to assess the carotid arteries of the client. Which assessment technique would be appropriate for the nurse to use?
Palpate one artery at a time.
Which is the most appropriate example of the assessment phase of the nursing process?
Palpating a mass in the right lower quadrant of the abdomen
A home health nurse states to her client, "I am very proud of you. You gave your first insulin injection without a problem. You have done wonderfully and are learning fast." What technique is the nurse using to compliment the client's progress?
Positive feedback
A 46-year-old obese client has been diagnosed with hypertension and type 2 diabetes. The client acknowledges the need to lose weight. The client recently visited a local fitness club, obtained a membership, and has signed up for their next water aerobics class. According to the Transtheoretical Model of Change, what stage of change is this client in related to her weight loss?
Preparation
A nurse has developed a plan of care for an adult client. What nursing function is important when using nursing diagnoses to guide the care of this client?
Prioritize the nursing diagnoses.
A nurse is shaving a male client's face. Which should the nurse do?
Pull the skin taut and shave in the direction of hair growth using short strokes.
A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse?
Pulse is felt with difficulty and disappears with slight pressure.
A nurse is shampooing a client's hair while the client is in bed. Which intervention should the nurse make to reduce back strain while performing the procedure?
Raise the bed to elbow height.
The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure?
Raise the head of the bed to a sitting position.
The nurse is preparing the client to use the hypothermia blanket. How does the nurse measure the client's temperature while the blanket is in use?
Rectal probe continuously
The nurse is caring for an obese client who needs to be turned every 2 hours. Which action by this nurse is an example of reflection-for-action?
Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care.
Which term refers to a purposeful activity that leads to action, improvement of practice, and better client outcomes?
Reflection
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.
Which nursing action is appropriate when providing foot care for a client?
Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms.
The nurse is conducting a community health promotion class and has developed scenarios that will involve active participation by the class attendees. What type of education strategy is the nurse incorporating into this class?
Role-playing
A client is undergoing chemotherapy for ovarian cancer which has metastasized. She has been experiencing increased nausea and vomiting associated with treatment. Which is an internal resource that the client has to help her attain her self-care goals?
She has motivation to participate in self-care.
Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight?
Shift their weight back and forth, from back leg to front leg.
A nurse may attempt to help a client solve a situational crisis during what type of counseling session?
Short-term counseling
The nurse is caring for a client with rectal bleeding. The nurse will place the client into which position to facilitate rectal examination?
Sims'
The nurse is providing oral care to an unconscious client. Which piece of equipment would be important to use in order to individualize care for this client?
Suction toothbrush
The nurse prepares to take a temperature of a client admitted with a myocardial infarction. The client is eating breakfast. Which action should the nurse choose?
Take the temperature using the axillary route.
Which intervention is most appropriate for a client newly diagnosed with diabetes and a nursing diagnosis of Deficient Knowledge?
Teach the client how to administer insulin.
When establishing a teaching-learning relationship with a client, it is most important for the nurse to remember that effective learning can best be achieved through which concept?
The client and the nurse are equal participants.
Which observation during the nursing assessment of a client supports the documentation of low health literacy?
The client avoids health care screenings and seeks care in the local emergency department.
A Chinese client who was previously treated at the health care facility for an open wound has been admitted again because the wound has become gangrenous. It has been identified that the client failed to understand proper wound care. What is the probable reason for the client failing to understand the instruction?
The client belongs to a different culture.
A nurse is educating a client with a new diagnosis of diabetes. Which example demonstrates cognitive learning by the client?
The client describes signs and symptoms of hypoglycemia.
The nurse is obtaining vital signs for a client and assesses a heart rate of 124 beats per minute. What additional assessment information would be important to obtain that would explain the tachycardia? Select all that apply.
The client has reports of pain of 8 on a scale of 0 to 10 The client has a temperature of 101.8°F (38.8°C) The client just finished ambulating with physical therapy
A female nurse is assisting an older man who has dementia with a bath in his hospital room. Which approach should the nurse take?
The client should be allowed to complete as much of the bath as he can.
A nurse is caring for a client with a decreased level of consciousness (LOC). When performing mouth care, what action by the nurse will decrease complications of oral care?
The client should be placed in a side-lying position to prevent aspiration.
The nurse is providing instructions to a client about performance of breast self-examination. What learning outcome would be most appropriate regarding this education?
The client will be able to perform proper breast self-examination for breast cancer detection and prevention.
When administering beta blocker medications, the physician adds an order to hold medication when the client is bradycardic. Which statement explains this order?
The client's pulse rate is below 60 beats per minute.
A nurse is assessing a client's blood pressure manually. The nurse should identify the client's systolic blood pressure (SBP) when which event occurs?
The first faint, but clear, sound appears.
While applying dressings to a client's wound, the nurse teaches the client about wound care. To promote the most effective teaching-learning relationship with this client, what would be mostimportant for the nurse to keep in mind?
The nurse and client relationship is based on mutual sharing and negotiation.
When a nurse is planning for learning, who must decide who should be included in the learning sessions?
The nurse and the client
A client is brought to the emergency department in an unconscious state with a head injury. The client requires surgery to remove a blood clot. What would be the appropriate nursing intervention in keeping with the policy of informed consent prior to a surgical procedure?
The nurse ensures that the client's family signs the consent form.
After reporting to work for a night shift, the nurse learns that the unit is understaffed because two RNs called out sick. As a result, each nurse on the unit must provide care for four acute clients in addition to the nurse's regular clients. Which statement is true for this nurse when working in understaffed circumstances?
The nurse is legally held to the same standards of care as when staffing levels are normal.
A nurse is communicating the plan of care to a client who is cognitively impaired. Which nursing actions facilitate this process? Select all that apply.
The nurse maintains eye contact with the client. The nurse shows patience with the client and gives the client time to respond. The nurse keeps communication simple and concrete.
A physician is called to see a client with angina. During the visit the physician advises the nurse to decrease the dosage of atenolol to 12.5 mg. However, because the physician is late for another visit, the physician requests that the nurse write down the order for the physician. What should be the appropriate nursing action in this situation?
The nurse should ask the physician to come back and write the order
A nurse is ambulating a client. The client catches her foot on the bed frame and begins to fall. How should the nurse best prevent or minimize damage from this fall?
The nurse should gently slide the client down his or her body to the floor.
Using proper body mechanics, which motions would the nurse make to move an object?
The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling.
A client is admitted to a hospital unit with scleroderma. The nurse is unfamiliar with this condition. What is the nurse's best source of information about this condition?
The nursing and medical literature
The nurse is teaching the parents of an infant with an irregular heartbeat how to check the pulse rate. The infant's pulse is very high and irregular. What will the nurse have to do in order to teach these parents how to monitor their infant's pulse rate?
The parents will have to be taught how to use a stethoscope so that they can listen to and count the infant's apical pulse.
A nurse is explaining to a nursing student why blood pressure is a frequently used assessment parameter in a wide variety of care settings. What can be inferred from an assessment of a client's blood pressure?
The resistance that the client's heart must overcome when pumping blood
A dialysis nurse is educating a client on caring for the dialysis access that was inserted into the client's right arm. The nurse assesses the client's fears and concerns related to dialysis, the dialysis access, and care of the access. This information is taught over several sessions during the course of the client's hospitalization. Which phase of the working relationship is best described in this scenario?
The working phase
A parish nurse is preparing to provide a health promotion class to a group of adults in the parish. In preparing to meet the learning needs of this group, the nurse recognizes which as a characteristic of an adult learner?
Their readiness to learn is often related to a developmental task or social role.
Nurses complete incident reports as dictated by the agency protocol. What is the primary reason nurses fill out an incident report?
To improve quality of care
A client was admitted to a postoperative nursing unit after undergoing abdominal surgery. During this time, the nurse failed to recognize the significance of abdominal swelling, which significantly increased during the next 6 hours. Later, the client had to undergo emergency surgery. The lack of action on the nurse's part is liable for action. Which legal term describes the case?
Tort
A nurse is caring for a client who has undergone coronary angioplasty. The cardiac monitor is showing abnormal electrocardiogram waves, indicating atrial fibrillation. The nurse does not recognize the importance of the sign; as a result, the client's condition deteriorates and the client has to be taken up for an emergency procedure. Which describes the nurse's legal liability?
Tort
The nursing process is based upon the process of problem solving. The nurse attempts to obtain a blood pressure on the client's right arm, then on the left arm, then on the left leg, and finally on the right leg, where the blood pressure is obtained. What type of problem solving did the nurse use?
Trial-and-error problem solving
During measurement of a rectal temperature, the thermometer probe should be inserted about 1.5 inches (3.8 cm) in an adult and 0.5 inches (1.3 cm) in an infant.
True
The nurse is performing vital signs for several clients. When assessing body temperature, what should the nurse take into consideration? Select all that apply
Tympanic temperature readings closely reflect core body temperature. An oral temperature may be taken if the client has oxygen by nasal cannula. Temporal artery thermometer readings may be affected by perspiration or air blowing over the face.
The nurse is providing care for a client and observes that the eyeglasses are cloudy and soiled. What action should the nurse take to be sure the lenses are clean and not damaged during cleaning?
Use a special cleaning solution for eye glass lenses
The nurse is caring for a client who is on warfarin therapy. Which teaching will the nurse provide?
Use an electric razor for shaving purposes.
A nurse providing hygiene and bathing for older adult clients knows that additional safety measures may be necessary in their care. The nurse delegates some aspects of care to an unlicensed assistive personnel (UAP). Which of the following are true regarding safety of the older adult while bathing? Select all that apply.
Use of a tub/shower seat may be necessary if balance problems are present. Water temperature should be monitored carefully due to decreased temperature sensation. Use a long-handled shower brush or attachment to help with limited mobility.
Which modification to bathing should be implemented for a client who is incontinent?
Use special perineal skin cleaners and moisture barriers.
When assessing an infant's axillary temperature, it will be:
When assessing an infant's axillary temperature, it will be:
A client's job requires moving heavy objects from one surface to another. The nurse will provide which anticipatory guidance to help this client avoid a back injury? Select all that apply.
Work as closely to the objects you are moving as possible. Flex the knees to improve balance and strength. Face in the direction in which you are moving the load.
An 80-year-old client has a body temperature of 97°F (36°C). Which condition best accounts for this client's temperature reading?
advanced age
A nurse is on lunch break in the hospital cafeteria and sits at a table near a group of physicians eating their lunch. One of the physicians, who is in charge of the nurse's clients, points at the nurse and states, "That guy needs to get fired." The best response by the nurse would be to:
ask to speak to the physician in private and address the disrespectful remark.
A client arrives at the emergency department after experiencing several black, tarry stools. The nurse should assess for the cause of the client's complaint by:
asking the client whether the client has recently taken ferrous sulfate (iron) or bismuth subsalicylate
An obese client has developed peripheral edema as a consequence of heart failure, making it very difficult for the student nurse to accurately palpate the client's peripheral pulses. How should the nurse proceed with this assessment?
auscultate the client's apical pulse
An ultrasonic Doppler is used for:
auscultating a pulse that is difficult to palpate.
A nurse is providing care to a client confined to bed. To promote independence while the client is moving in bed and provide the client assistance in moving up in bed, which device would be appropriate?
bed trapeze
A nurse needs to count a client's apical heart rate. Which assessment site is most suitable for counting the apical heart rate?
chest
A client has had major abdominal surgery and just returned to the unit from the operating room. The nursing priority is to:
complete the postoperative assessment.
An obese client is in the clinic to start on a weight loss plan. The client loves to eat. The client's favorite food is hamburgers. The client does not like to exercise. The nurse creates a nursing diagnosis of ineffective health maintenance to include in the plan of care. What is the mostappropriate outcome for this nursing diagnosis for the client? The client will:
create an exercise plan that is realistic and valued.
An experienced nurse is educating a client about the client's disease and how best to promote optimal health. The nurse is focusing the education on the cognitive domain of learning. Given this focus, the nurse would incorporate the client's:
critical thinking.
A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse can anticipate that the digoxin will:
decrease the apical pulse.
A client has smoked most of his life and has labored respirations. He is experiencing:
dyspnea
The nurse needs to understand the teaching-learning process when administering
educational interventions.
The client is a clerical assistant for an inpatient hospital unit. He spends most of his day at a desk. What would the nurse advise the clerical assistant to do to minimize damage to his musculoskeletal system? Select all that apply.
face in the direction of the activity he is performing use a wide stance and lift with the large leg muscles adjust the height of the work area
When a black adolescent client asks the nurse how to care for long hair, which is braided into small braids, the nurse should instruct the client that:
hair should be washed as often as necessary.
The purpose of obtaining a nursing history is to:
identify actual and potential health problems.
A client reports feeling "different" than earlier in the day. When would the nurse anticipate assessing vital signs?
immediately
When the nurse cleanses the client's leg during a bed bath, it will allow for:
increased circulation.
The temperature is 102°F (39°C) during a heat wave. The nurse can expect admissions to the emergency room to present with:
increased temperature.
During the introductory phase of interviewing a client for the purpose of obtaining information for the nursing history, the nurse should:
inform the client of the maintenance of confidentiality.
When logrolling a client, the nurse should use supportive devices in turning the client in order to:
maintain the natural alignment of the client's body.
After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client sit up on the side of the bed?
near the client's hip, with legs shoulder width apart and one foot near the head of the bed
A nurse is filling out an incident report after an older adult client fell while attempting to transfer from her bed to a commode. Which health problem should the nurse consider when client falls occur?
orthostatic hypotension
When assisting a client from the bed into a wheelchair, the nurse assesses the client for signs of dizziness upon standing. For what adverse condition is the nurse assessing the client?
orthostatic hypotension
A nurse identifies the following: "The client will report a pain rating of 4 or less within 30 to 45 minutes of receiving prescribed analgesic." The nurse has identified:
outcome.
A kindergarten student is sent to the school nurse because she has been vigorously scratching her scalp for a few hours. The nurse's first action will be to assess the child for the presence of:
pediculosis
Which health problem is most clearly suggestive of a history of inadequate dental care?
periodontitis
A nurse is caring for a client who presents with a skin infection. While obtaining the client's medical history, it is determined that the client is an intravenous drug user. To foster effective communication, the nurse should:
remain honest, open, and frank.
The pediatric nurse is caring for a 3-week-old infant. In which position will the nurse place the infant to sleep?
supine
The pediatric nurse is caring for a newborn infant. In which position will the nurse place the infant to sleep?
supine
The nurse is assisting a client with limited mobility to turn in bed. After successfully turning the client to the side, where would the nurse place an additional pillow?
supporting the client's back
Which are considered vital signs? Select all that apply.
temperature pulse respiratory rate blood pressure
A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which observation can be made by the nurse and athletes by measuring the blood pressure?
the ability of the arteries to stretch
A pulse deficit is the difference between:
the apical pulse and the radial pulse rates.
When assessing the physical activity of clients, the nurse would be most concerned about which client?
the middle-aged computer programmer
The nurse is providing health teaching for a client who flies often for business. Which risk factor associated with flying will the nurse emphasize?
thrombus formation
The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is mostappropriate to assist in transferring?
transfer belt
The nurse is working to increase functional ability with a client. Which assistive technique should be included in the plan of care?
trapeze bar
When an adult client from Indonesia refuses a complete bath on the day after abdominal surgery, the nurse should:
understand that his culture may influence his hygiene and ask him his preference.
A nurse is providing care to a client who has limited understanding of the dominant language. Which strategy is best for the nurse to use to ensure that the client obtains the needed health information?
Enlist the services of a qualified language interpreter
Paramedics arrive in the emergency department with a client who was in a motor vehicle collision. The paramedic reports that the driver was restrained, the car was traveling about 30 miles per hour (48 km/hr), and the air bags were not deployed. The paramedic continues to report that the car was struck from behind and that all individuals in the car were able to self-extricate. Which statement made by the nurse is verifying the report from the paramedic?
"All of the people got themselves out of the car?"
The nurse is caring for a client who is postoperative 24 hours from an appendectomy. The client is hesitant to get out of bed. How should the nurse respond?
"Can you describe what you are feeling when you try to move?"
The clinic nurse is obtaining demographic data from a client. The client states, "Why do you need to know what my ethnicity is?" How should the nurse respond?
"Collecting this information allows us to develop a personalized plan of care to meet your needs."
A nurse is discussing cataract treatment with a client. Which statement by the nurse would be mosttherapeutic?
"Have you ever thought of laser surgery?
A nurse confides in a nurse friend, "I never report minor incidents. The charge nurse always wants a variance report filled out and they take so much time." Which responses by the friend are indicated? Select all that apply.
"Having documentation might keep you out of trouble someday." "Reporting helps us fix problems that result in danger to clients."
While a client admitted to the medical-surgical unit is in the radiology department, a visitor claiming to be the client's cousin arrives on the medical-surgical unit and asks the nurse to provide a brief outline of the client's illness. Which response by the nurse would be most appropriate, both legally and professionally?
"I cannot give you that information due to client confidentiality."
The nurse has arranged to start an IV line for a client with pancreatitis. The nurse notes that the client appears anxious about the procedure. What is the most appropriate response by the nurse to decrease the client's anxiety?
"I will start an IV that will add fluids directly to the blood stream."
The staff nurse overhears the charge nurse, who is of Italian heritage, talking to the unlicensed assistive personnel. Which statement made by the charge nurse is an example of ethnocentrism?
"Italians are best at everything."
A client being discharged from the hospital asks the nurse, "When I go visit my family out of state, should I take my living will with me, or do I need a new one for that state?" Which is the mostappropriate response by the nurse?
"Take it with you. It is recognized universally in the United States."
A nurse tells the charge nurse about difficulty obtaining the client's cooperation in providing care. What would be the charge nurse's most appropriate response?
"The best way to obtain your client's cooperation is by first obtaining your client's trust.
A client is scheduled for thoracentesis. The nurse assesses that the client appears anxious about the procedure and needs honest support and reassurance. What is the most appropriate response by the nurse to this client?
"The needle causes discomfort or pain when it goes in, but I will be by your side throughout and will help you hold your position."
Action has been taken against a nurse's license based on a claim that the nurse acted outside of nursing's scope of practice. The nurse's attorney determines that the nurse needs more education about the purpose of the board of nursing when the nurse makes which statement?
"The rules made by the board of nursing don't reflect my practice."
A client with a cardiac dysrhythmia was recently prescribed metoprolol and is at a follow-up appointment at the cardiologist's office. The client tells the nurse, "I feel depressed, tired, and I have no desire to exercise." To determine a cause-and-effect relationship, the nurse should ask:
"Were you tired and depressed before starting the new medication?"
A nurse is admitting a client to the unit. Which cultural question is most appropriate?
"What are your dietary needs and preferences?"
The nurse is caring for a client 4 days after total hip arthroplasty and notes the client has lost weight. The unlicensed assistive personnel reports the client's food intake has decreased. Which question will the nurse ask the client to determine if cultural causes are responsible for the weight loss?
"What type of food do you like to eat at home?"
Which is an open-ended question?
"Why did the health care provider prescribe this medication for you?"
A nurse is assessing vital signs on a pregnant client during a routine prenatal visit. The client states, "I know labor will be so painful, it sounds awful. I am sure I will not be able to stand the pain; I really dread going into labor." What is the best response from the nurse?
"You're worried about how you will tolerate the pain associated with labor."
A nurse caring for clients of different cultures in a hospital setting attempts to make eye contact with clients when performing the initial assessment. What assumption might the nurse make based on common cultural practices?
A Muslim-Arab woman refuses to make eye contact with her male nurse. Assumption: She is being modest.
A nurse and client are in the working phase of the helping relationship. What outcome statement developed by the nurse and client correlates with this phase?
A nurse and client are in the working phase of the helping relationship. What outcome statement developed by the nurse and client correlates with this phase?
Which is an example of an unintentional tort?
A nurse gives the client a medication, and the client has an adverse reaction to it.
In which situation would the SBAR technique of communication be most appropriate?
A nurse is calling a physician to report a client's new onset of chest pain.
Which scenario is an example of certification?
A nurse who demonstrates advanced expertise in a content area of nursing through special testing
What is the priority assessment for the nurse when developing a plan of care for a client living in poverty?
Access to care
The nurse is assessing an older adult who immigrated at the age of 3 years. The client speaks the dominant language and lives in a neighborhood with many households from the country of origin. Which action by the nurse is most appropriate?
Ask the client about special cultural beliefs or practices.
A client informs the nurse about leaving the health care facility because the client is not satisfied with the treatment. The nurse knows that the client's treatment is incomplete and further testing and evaluations are scheduled. Which action by the nurse would be most appropriate to prevent false imprisonment?
Ask the client to sign a release without medical approval.
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
Which scenario is an example of cultural competence in nursing?
Attending a conference for cultural diversity
Which behavior by the nurse is stereotyping?
Avoiding older adult clients because their care is time consuming
A nurse working in a coronary care unit resuscitates a client who had expressed wishes not to be resuscitated. Which tort has the nurse committed?
Battery
A nurse fails to communicate a change in the client's condition to the physician. Which element related to proving malpractice has been met?
Breach of duty
Having recently completed a specialty nursing program in neonatal care, a nurse is now preparing to leave the medical unit and begin providing care in the hospital's neonatal intensive care unit (NICU). The nurse has completed which process of credentialing?
Certification
Nurses practicing in a critical care unit must acquire specialized skills and knowledge to provide care to the critically ill client. These nurses can validate this specialty competence through what process?
Certification
A nurse is conducting a cultural assessment of a client. Which person would the nurse identify as the expert?
Client
Which is a skill appropriate to use in therapeutic communication?
Control the tone of the voice to avoid hidden messages.
A client believes that the illness is caused by an imbalance of yin and yang. The nurse states, "You can call it whatever you believe, but you have a metabolic disorder." What is this nurse demonstrating?
Cultural blindness
The emergency department nurse is caring for a client injured in a motor vehicle collision. The client recently immigrated to the country. The nurse should implement interventions aimed at addressing which issue?
Culture shock
A client states that the client's recent fall was caused by his scheduled antihypertensive medications being mistakenly administered by two different nurses, an event that is disputed by both of the nurses identified by the client. Which measure should the nurses prioritize when anticipating that legal action may follow?
Document the client's claims and the events surrounding the alleged incident.
The client is admitted to the hospital with a ruptured ovarian cyst. The client has expressed that it is very important that the spouse be present to receive all medical information. Using the concepts of culturally competent care, which is the best response?
Document the client's request in the nursing care plan.
In some cases, the act of providing nursing care in unexpected situations is covered by the Good Samaritan laws. Which nursing action would most likely be covered by these laws?
Emergency care for a choking victim in a restaurant
A family has lost a member who was treated for leukemia at a nursing unit. The nurse provides emotional support to the family and counsels them to cope with their loss. Which quality should the nurse use in this situation?
Empathy
When assessing a client's nonverbal communication, the nurse should assess which aspect as being the most expressive?
Facial expressions
The client is an 18-month-old in the pediatric intensive care unit. The client is scheduled to have a subgaleal shunt placed tomorrow, and the client's mother is quite nervous about the procedure. The nurse tells the client's mother, "The surgeon has done this a million times. Your son will be fine." This is an example of what type of nontherapeutic communication?
False reassurance
Which area is typically included in a cultural assessment?
Food preferences
A nurse who obtains a license to practice nursing through self-misrepresentation is guilty of what tort?
Fraud
The nurse is caring for a client from another culture who is diagnosed with lung cancer. Which nursing action best demonstrates culturally sensitive care?
Incorporating the client's need for daily prayer into the nursing care plan.
A nurse talks with family members about an AIDS client from the clinic where the nurse works. Which tort has the nurse committed?
Invasion of privacy
An HIV-positive client discovers that the client's name is published in a research report on HIV care prepared by the client's nurse. The client is hurt and files a lawsuit against the nurse. Which offense has the nurse committed?
Invasion of privacy
A nurse is part of an orientation team for a group of newly hired nurses. The nurse is to prepare a presentation for the group about different cultural groups common to the facility. As part of the presentation, the nurse is planning to describe how culture is communicated to provide a foundation for culturally competent care. Which methods of communication would the nurse include? Select all that apply.
Language Behavior Symbols
Which nursing action displays linguistic competence?
Learning pertinent words and phrases in the client's language
A nurse is caring for a client following endotracheal intubation. Before applying soft wrist restraints to prevent the client from pulling out the endotracheal tube, what is the most appropriate action of the nurse?
Obtain a medical order.
A nurse enters the client's room and states, "Hello, Mr. Alonso. My name is Anthony Bader. I will be your registered nurse today. I will be providing your nursing care and will be with you until 3:30 PM. If you need anything, please call me on my phone or put your light on." The nurse then gives the client a printed card with this information. In the helping relationship, which phase does this represent?
Orientation phase
The nurse makes a contract with the client during which phase of the nurse-client relationship?
Orientation phase
Which behaviors demonstrated by the client would the nurse consider reflections of the client's pride in ethnicity? Select all that apply.
Requesting native cuisine Listening to folk music and dance Asking to wear unique clothing
A newly hired young nurse overheard the charge nurse talking with an older nurse on the unit. The charge nurse said, "All these young nurses think they can come in late and leave early." What cultural factor can the new nurse assess from this conversation?
Stereotyping
A nurse witnesses a traffic accident and dresses the open wounds sustained by a child. Later, in the hospital, the child develops complications from an infection in the wound. The family holds the nurse responsible for the complications and attempts to file a lawsuit. Which statement is true regarding how the Good Samaritan law applies to this case?
The Good Samaritan law will provide legal immunity to the nurse.
What governing body has the authority to revoke or suspend a nurse's license?
The State Board of Nurse Examiners
A new client comes to the primary care clinic and asks for help treating head lice. The nurse assesses that the client lives in low-income housing, and nine other people live with the client in a one-bedroom apartment. Which consideration is the priority nursing concern?
The client does not have running water.
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?
The client is holding pressure on the abdomen when speaking.
In addressing health promotion for a client who is a member of another culture, the nurse should be guided by which principle?
The client may have a very different understanding of health promotion.
A nurse convinces a client who is a Jehovah's Witness that receiving blood products is more important than the legalistic components of religion. What client reaction may be expected following this mandated change?
The client states, "I feel like I abandoned my religion."
A client is unhappy with the health care provided and informs the nurse that the client is leaving the facility. The client has not been discharged by the physician. The nurse finds that the client has dressed and is ready to go. What should the nurse's action be in this situation?
The nurse should call and inform the nursing supervisor of the situation.
While at a coworker's house, a nurse discusses with the coworker a client whom the nurse suspects of physically abusing the client's child. The next day, the client is moved to another nursing unit after a surgical procedure and comes under the care of the coworker, who is also a nurse. The coworker confronts the client about the alleged physical abuse. The client is shocked and angered by the accusation and denies it categorically. What would be the charge if the client were to file a suit?
The first nurse could be charged with slander.
Which best exemplifies malpractice?
The nurse administers amoxicillin to a client with known allergies to penicillin. The client has a seizure with resulting respiratory arrest.
Which statement accurately describes the concept of feedback as it pertains to the process of communication?
The sender and the receiver use one another's reactions to produce further messages
A student nurse is assisting an older adult client to ambulate following hip replacement surgery when the client falls and reinjures the hip. Who is potentially responsible for the injury to this client?
The student nurse, the nurse instructor, and the hospital
Which is a cultural norm of the health care system?
There is the use of a systematic approach and problem-solving methodology.
Which are examples of a nurse appropriately protecting a client's privacy? Select all that apply
With the client's permission, the nurse explains the client's diagnosis to the client's spouse. The nurse moves the client from the emergency department waiting room to a private area to collect assessment data.
Care provided to a client following surgery and until discharge represents which phase of the nurse-client relationship?
Working phase
he nurse working on a medical unit always performs hand hygiene between contact with each client. In addition to being understood as an infection control measure, this practice can be understood as:
a ritual.
A nurse is attempting to complete an admission database. While taking the history, the nurse notices the client appears uncomfortable and slightly tachypneic. The nurse should:
allow the client to set the pace.
A legal document that states a client's health-related wishes — such as a preference for pain management if the client becomes terminally ill — and also allows the client's adult child to direct the client's care, is:
an advance directive.
A nurse suspects that a client may have a hearing problem. The nurse should attempt to consult:
an audiologist.
Carl Rogers (1961) studied the process of therapeutic communication. Through his research, the elements of a "helpful" person were described. They include all of the following except which choice?
analysis
A nurse has been working on a telemetry unit for 6 months. The nurse arrives at work in the morning and overhears a night shift nurse talking about the new nurse. The night shift nurse is heard saying, "That new nurse is only here to meet a doctor and get married." The best response by the new nurse would be to:
ask to speak to the night shift nurse in private and explain how the comment made the new nurse feel.
Nurses are responsible for delivering culturally competent care for all clients. Culturally competent care does not account for:
client's height.
A nurse is preparing to provide discharge instructions to a postpartum client regarding infant care. Before beginning the education session, the nurse should:
eliminate as many distractions as possible.
Nurses are socialized into the:
healthcare culture.
When the nurse informs a client's employer of the client's autoimmune deficiency disease, the nurse is committing the tort of:
invasion of privacy.
While riding in the elevator, a nurse discusses the HIV-positive status of a client with other colleagues. The nurse's action reflects:
invasion of privacy.
A nurse is providing care to a 3-year-old child admitted with a diagnosis of infectious diarrhea. The nurse needs to insert an intravenous catheter in order to administer prescribed intravenous fluids. In an attempt to foster communication, the nurse should:
involve the child's stuffed animal in the educational session.
A client says to the nurse, "Why don't you wear a white cap like nurses do on the soap operas?" This is an ethnocentric statement based on the:
media.
A nurse is at the end of a busy shift on a medical-surgical unit. The nurse enters a room to empty the client's urinary catheter and the client says, "I feel like you ignored me today." In response to the statement, the nurse should:
sit at the bedside and allow the client to explain the statement.
A nurse is overheard in the hospital cafeteria making false, derogatory comments about a client. The nurse is guilty of:
slander.
A nurse is attempting to calm an infant in the nursery. The nurse responds to the highest developed sense by:
swaddling the child and gently stroking its head.
A nurse is preparing to enter a client's room to perform wound care. The shift report revealed that this client has a tunneling wound in the sacral area that cannot be staged. The wound was also documented as having a foul odor. The nurse is nervous because the nurse has not performed wound care on a complex wound in the past. Using effective intrapersonal communication, this nurse should:
tell oneself to "remain calm" and remember that the nurse was trained to perform this skill.