Professional Nursing Exam 3

The nurse is preparing a client for surgery and asks if the client has an advance directive. The client asks "What is an advance directive?" What is the nurse's best response to this?

"An advance directive will communicate your wishes for health care postoperatively in case you are unable to do so."

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."

The nurse is taking a history for a client who is being seen for chronic unrelieved back pain. Which assessment question helps the nurse assess duration of pain?

"How long have you experienced this pain?"

Which statement, if made by an adolescent preparing for abdominal surgery, would indicate to the nurse that the client requires additional instruction?

"I can have a hamburger and French fries as soon as I wake up."

The nurse is teaching a client how to manage postoperative pain through a patient controlled analgesia (PCA) pump. The nurse determines that additional teaching is needed when the client make which statement?

"I should only take medication when my pain is intense."

A nurse is evaluating the effectiveness of the preoperative education regarding pain control. Which statement by the client would indicate a need for further education?

"I will have my wife push the PCA button when I'm asleep."

A client has been prescribed patient-controlled analgesia and the nurse is setting up the system and educating the client about safe and effective use of PCA. Which teaching point should the nurse provide to the client?

"The pump is programmed so that it's not possible for you to overdose on your pain medication."

A client will be having a surgical procedure requiring general anesthesia. Which desired outcomes of general anesthesia does the nurse expect to observe? Select all that apply. -depressed reflexes -analgesia -relaxed skeletal muscles -loss of consciousness

-depressed reflexes -analgesia -relaxed skeletal muscles -loss of consciousness

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

A nurse attempts to relieve the pain of a client by using cutaneous stimulation. Which of the following describes usage of this technique?

A nurse applies intermittent heat and cold to a client's leg.

The nurse caring for a client receiving opioid therapy notes that the client's respirations are 7. What is the first action by the nurse?

Administer naloxone

A client is prescribed pain medication every 4 to 6 hours as needed. When the nurse enters the client's room to administer the medication, the client is laughing with visitors. The client's pulse rate is 64, respirations 16, and blood pressure 120/80. The client reports pain and wants the medication. What is the most appropriate action by the nurse?

Administer the pain medication

A 2-year-old toddler just underwent a tonsillectomy and adenoidectomy surgery. The postanesthesia care unit (PACU) nurse is checking on him. What is the best course of action regarding the developmental care of this child?

Allow the parents into the PACU before the child wakes.

The nurse is teaching a client with diabetes how to inject daily insulin. Which method is most effective in evaluating the teaching?

Ask the client to demonstrate how to self-inject the morning insulin.

A client is postoperative day 1 and the nurse's assessment reveals signs of pain, such as grimacing and guarding. Which is the most reliable method for assessing the client's pain?

Ask the client to describe and rate his or her pain.

A nurse works with an older adult client who has two broken femurs. The client does not report pain. Which action will the nurse take?

Assess the client for nonverbal cues of pain

The nurse is caring for an older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first?

Assess the need for assistance with ambulation.

A nurse manager informs the staff members during a meeting that unlicensed assistive personnel will no longer be allowed to check clients' blood glucose levels. The nurse manager informs the group that this is a new policy on the unit and that discussions will not change the enforcement of this policy. What type of leadership style is the nurse manager demonstrating?

Autocratic

The registered nurse on a busy telemetry floor is delegating tasks to an unlicensed assistive person (UAP). Which task is appropriate for the UAP to complete?

Bathing a combative client

The nurse is working at a facility that is applying for Magnet® Recognition. The nurse knows that compared with other hospitals, Magnet® hospitals have which direct effect on client care?

Better patient outcomes

The nurse is working to enhance time management skills and has to administer pain medications to several patients, obtain vital signs, and assist clients with bathing. What should the nurse do next?

Delegate bathing and vital signs tasks

A staff nurse works on a medical unit where staff retention is very high. There is a sense of equality between the leader and the staff nurses. The unit decisions and activities are shared between the leader and the group. The designated nurse leader practices which leadership style?

Democratic

The nurse manager who asks staff members to give suggestions on how to improve collaboration between nurses and physicians is exhibiting what style of leadership?

Democratic

The nurse is completing documentation after an education session with a client. Which statement best demonstrates detailed documentation of an effective teaching plan?

Demonstrated cord care to mother, who stated understanding and performed return demonstration using correct technique

A client diagnosed with type 2 diabetes has been prescribed insulin therapy in conjunction with an oral agent because the client has been experiencing difficulty controlling blood sugar levels with an oral agent alone. The nurse is preparing a teaching plan for this client. Which intervention would the nurse include in the teaching plan to address the psychomotor domain?

Demonstrating the technique for insulin self-injection

The nurse manager is concerned about the large number of teenage mothers being seen in the obstetrics clinic. How can the nurse manager use the transformational leadership style to address the concern?

Enlist volunteers to help develop a community outreach project that will educate teenagers on methods to prevent pregnancy.

A nurse can improve one's skill with time management by taking which action?

Evaluating success with accomplishment of goals in client care

A nurse is preparing to teach a 6-year-old client with a broken arm and the client's mother about caring for the child's cast. Which statement reflects the best education plan for these clients?

Include the child in the education; ask questions of both the mother and the child.

Which surgical clients will return to activities in their everyday lives more quickly?

Laparoscopic cholecystectomy

A client had an open cholecystectomy (gallbladder removal) 36 hours earlier, and the nurse's assessment this morning confirms that the client has not yet had a bowel movement since prior to surgery. How should the nurse best respond to this assessment finding?

Monitor the client closely and promote fluid intake.

A nurse on a telemetry unit is admitting a client and has an unlicensed assistive person (UAP) helping with the admission process. Which task can the nurse delegate to the UAP?

Obtaining an admission weight for the client utilizing the client's bed scale

A client reports severe pain following a mastectomy. The nurse would expect to administer what type of pain medication to this client?

Opioid analgesics

A pediatric nurse provides education to numerous clients. Which group of children benefits mostfrom being involved in the teaching-learning process?

School-age children

A nurse manager best demonstrates effective leadership characteristic by which action?

Sharing a vision for the unit and enlisting support

The nurse recognizes that a new mother is having difficulty breastfeeding. The nurse demonstrates various positions in which to hold the baby while feeding. The nurse also educates the mother on ways to ensure proper latching. The new mother attempts to breastfeed the baby again using the new techniques and is successful. Which statement in this scenario illustrates Lewin's stage of refreezing?

The new mother attempts to breastfeed the baby again using the new techniques and is successful.

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.

The registered nurse (RN) wants to delegate a task to an unlicensed assistive personnel (UAP) but is unsure if the task can be delegated. What is the best resource for the RN to use in determining if the task is appropriate?

The nurse practice act or facility's policy and procedures

When teaching an adult client how to control stress through relaxation techniques, the nurse should proceed on the basis of which assumption concerning adult learners?

The nurse should be able to draw from the previous experience of the client to emphasize the importance of stress reduction.

The nurse is employing gate theory in the care of a client with pain in the lower back. What actions by the nurse may assist in pain relief for the client?

Use massage and heat application to the lower back

The triage nurse is assessing a 5-year-old client who has come to the emergency department with a caregiver after falling off of a skateboard. Which pain assessment tool will the nurse choose to use?

Wong-Baker FACES® scale

A nurse is teaching a client about the rationale for fasting from food and fluids prior to surgery. What condition does this measure attempt to avoid?

aspiration

An elder adult client underwent a hip replacement and now states to the nurse, "My parents are coming to visit me today. I need to mow the lawn and run errands." The client is trying to get out of the bed. What does the nurse identify is occurring with this client?

delirium

The recovery nurse is caring for a surgical client in the PACU. The client's blood pressure is dropping and the heart rate is increasing. The nurse suspects the client is:

developing shock

A client is undergoing surgery for an appendectomy. This would be considered what type of surgery?

emergency surgery

Which of the following is considered to be the most potent neuromodulators?

endorphins

A nurse is successful in promoting change on the nursing division. This nurse would be considered a:

leader

What is the nurse's role in the informed consent process for a surgical procedure?

witnessing the signed informed consent document

A 56-year-old client meets with the nurse for education about a recently diagnosed atrial fibrillation. The client verbalizes concerns about being away from work too long and doubts about the necessity of having blood tests every week, as the client has no symptoms. Which is the bestmotivational statement by the nurse for this client?

"The medicine and blood work can help prevent blood clots, which can lead to strokes. What do you know about warfarin therapy?"

The nurse is providing education about deep-breathing exercises to a postoperative client whose surgery took place earlier today. Which instruction should the nurse provide?

"Try to do your exercises every 1 to 2 hours."

The nurse is caring for a client after breast augmentation. Before performing a bowel assessment, what education will the nurse provide the client?

"You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or narcotics. By listening for bowel sounds, I can check for a return of peristalsis."

The nurse is providing education for a postoperative client regarding pain management. Which teaching point should the nurse include?

"You will receive pain medication by injection as long as you are NPO."

A nurse is preparing to educate about the importance of contraception and safe-sex practices to a group of college students. Which factors can affect the nurse's teaching strategies? Select all that apply. -Literacy level of target audience -Availability of resources -Economic status of target audience -Family background of target audience -Learning style preferences of students

-Availability of resources -Learning style preferences of students -Literacy level of target audience

A nurse is educating a 4-year-old client about cast care following a tibia-fibula fracture. Which action is not developmentally appropriate to include in the nurse's teaching?

Blocking 30 minutes of time for skill teaching

In the hospital setting, a nurse is responsible for overseeing the quality and financial outcomes of client care while working collegially with health care providers. What type of professional nursing practice is this considered?

Case management

When caring for a client, the nurse observes that the client enjoys reading books and magazines. In which learning domain does the client's learning style fall?

Cognitive

The nurse has recently been promoted to nurse manager on a pediatric unit and has decided to accept input from staff regarding changes they would like to see on the unit. Which type of leadership style is the nurse embodying?

Democratic

Which statement by a registered nurse (RN) represents appropriate delegation to a nursing assistant?

Dispose of the disconnected IV set

The nurse is performing a preoperative assessment of a client who has been scheduled for a reduction mammoplasty (breast reduction). The client states, "I'm starting to wonder if I made the right decision in going ahead with this." What should the nurse do next?

Explore the client's feelings and inform the surgeon.

A nursing facility has recently implemented new policies regarding nurse-to-patient ratios. The nursing staff seems very resistant to the change. How can the nurse manager help the staff accept the change?

Hold a unit meeting to discuss how the changes will benefit staff.

A client is scheduled for hip replacement surgery this morning but admits to the nurse that he had a small piece of toast and some water after waking up. What is the nurse's most appropriate response?

Inform the anesthesiologist or surgeon of this fact.

A 9-month-old baby is scheduled for heart surgery. When preparing this client for surgery, the nurse should consider which surgical risk associated with infants?

Potential for hypothermia or hyperthermia

When caring for a diabetic client, the nurse notes that the client learns better when practicing the self-administration of the insulin injection alone. In which learning domain does this client's learning style fall?

Psychomotor

Which strategy should the nurse use when providing education to the older adult client?

Remain calm and conduct the teaching session in a quiet environment

When teaching a client, the nurse notices the client tends to lose focus easily. The nurse would adapt client teaching in which way?

Talk with animation and vocal inflection to stimulate the client aurally.

A nurse implements cutaneous stimulation for a client as part of a strategy for pain relief. Which nursing action exemplifies the use of this technique?

The nurse gives the client a massage before bed

The nurse preparing to admit a client receiving epidural opioids should make sure that which of the following medications is readily available on the unit?

naloxone

A client with an amputated arm tells a nurse that sometimes he experiences throbbing pain or a burning sensation in the amputated arm. What kind of pain is the client experiencing?

neuropathic pain

A nurse manager reviews an employee's contribution to the nursing division annually. This process is:

performance appraisal

A nurse teaches deep breathing exercises to a client scheduled for surgery. In which perioperative phase would this action occur?

preoperative

A nurse assisting a new mother in the act of breastfeeding represents which form of learning?

psychomotor

A client describes pain in the lower leg and has been diagnosed with a herniated lumbar disk. The pain in the leg is what type of pain?

referred pain

Which of the following is the priority assessment for a nurse caring for a client with a Patient Controlled Analgesia (PCA) pump?

respiratory

A nurse evaluates whether a middle-age client with chronic back pain has been performing the different exercises and physiotherapy procedures recommended by the physician. What would the nurse most likely use to evaluate the client?

return demonstration

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 who has been harassed at her place of work tells the nurse, "Every time I think of my job, I get a debilitating headache and have to go lie down to make the pain go away." Which nursing intervention will the nurse perform to practice according to the Neuromatrix Theory?

teaching client to remove items from home that remind them of work

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 observes that a client who underwent knee surgery 2 weeks ago needs progressively larger doses of analgesics to get relief from pain. The nurse interprets this as:

tolerance