Test 3 Nursing Interventions

A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells?

1 unit over 2 to 3 hours, no longer than 4 hours

The nurse is assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade?

1+

The nurse is administering 1,000 mL 0.9 normal saline over 10 hours (set delivers 60 gtt/1 mL). Using the formula below, the flow rate would be: gtt/min = milliliters per hour x drop factor (gtt/mL) ÷ 60 min/hr

100 gtt/min

The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend?

2,500 mL/day

A physician has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing?

60 drops/mL

A health care provider orders a bolus infusion of 250 mL of normal saline to run over 1 hour. The set delivers 20 gtt/mL. What is the flow rate in gtt/min?

83 gtt/min

The nurse is calculating an infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 12 hours using an electronic infusion device. What is the infusion rate?

83 mL/hr

Which situation is most likely to warrant an autopsy?

A client's death involves an allegation of a medical error.

The wound care nurse is performing dressing changes for several clients on the unit. Which situation reinforces the nurse's competence in providing wound care? Select all that apply.

A nurse places a transparent dressing over a central venous access device insertion site. A nurse uses aseptic techniques when changing a dressing. A nurse places a drainage dressing around a drain insertion site.

A nurse is teaching a client with anxiety about the use of meditation. Which of these are important features of meditation? Select all that apply.

A quiet location An open attitude A comfortable position

A nurse is using the RYB wound classification system to document client wounds. Which wound would the nurse document as a Y (yellow) wound? Select all that apply.

A wound that is characterized by oozing from the tissue covering the wound A wound with drainage that is a beige color A wound that requires wound cleaning and irrigation

Which priority intervention should the nurse plan to implement to reduce a client's discomfort during terminal weaning?

Administer sedation and analgesia.

A nurse is conducting an in-service program for a group of hospice nurses. When describing the grief response in adults and older adults as compared to children, which would the nurse most likely include? Select all that apply.

Adults and older adults grieve more continuously. Children need to go through the same grief reactions as adults do Adults and older adults do not seek an immediate replacement for the lost loved one.

The nurse explains to the client which statement is true regarding the difference between allopathic therapy and complementary and alternative therapy?

Allopathic therapy emphasizes treatments for diseases. Complementary and alternative therapy emphasizes treatments for health.

A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs?

An implanted central venous access device (CVAD)

A client states, "My children still need me. Why did I get cancer? I am only 30." This client is exhibiting which stage, according to Kübler-Ross?

Anger

What is the lab test commonly used in the assessment and treatment of acid-base balance?

Arterial blood gas

A nurse is caring for a client admitted for a prolonged stay on a medical-surgical unit. The client has been having difficulty sleeping and appears depressed. Applying the holistic health model, which action taken by the nurse would be most appropriate?

Ask the client's family to bring some items from home, such as a blanket, pillow, or pictures

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?

Assess the client's wound and vital signs.

A nurse can best help a client who is undergoing chemotherapy and using guided imagery with this by doing which of the following?

Assisting the client to find an appropriate imagery tape to use.

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?

Avoid salty or excessively sweet fluids.

Which of the following is an important aspect of Ayurveda?

Balancing of the doshas.

The nurse is educating a client on how to use herbs and supplements as part of an integrated treatment plan. Which teaching points would the nurse include? Select all that apply.

Buy herbs and supplements that are standardized. Give the product adequate time to work. Be knowledgeable about the product and its therapeutic actions.

The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level?

Cardiac dysrhythmias

A registered nurse is overseeing the care of numerous clients on a busy acute medicine unit. Which task would be most safe to delegate to a licensed practical nurse (LPN)?

Changing the dressing on a client's peripheral IV site

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?

Clean the wound from the top to the bottom and from the center to outside.

A client at a health care facility has died after a prolonged illness. A nurse is assigned to perform postmortem care for the client. Which intervention should the nurse perform when providing postmortem care?

Cleanse drainage from the skin.

In prenatal classes, the nurse teaches pregnant clients to use meditation during labor contractions to ease the pain. Which elements of meditation are important for the nurse to emphasize? Select all that apply.

Comfortable position Quiet environment Focus of attention

A client is in the last stage of labor. During each contraction, she is focusing on her husband's voice and a picture brought from home. She is demonstrating which type of meditation?

Concentrative

Which is not considered a skin appendage?

Connective tissue

The nurse has noted that a dying client is increasingly withdrawn and is often teary at various times during the day. The nurse recognizes that the client may be experiencing which of Kübler-Ross's stages of grief?

Depression

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound?

Desiccation

The nurse enters a client's room and finds the client curled up in bed and crying. The client states, "My life is so good, and now I have cancer. Why me? I have tried to be a good person." The nurse recognizes the client as exhibiting signs of which stage of Engel's model of grief?

Developing awareness

A child is brought to the clinic by a parent. The parent states that the child has been at camp. The child has a rash on the face, arms, and legs. The child states it itches severely. How will the nurse describe the assessment findings?

Diffuse dermatitis accompanied by pruritus

A nurse inspecting a client's IV site notices redness and swelling at the site. What would be the most appropriate nursing intervention for this situation?

Discontinue the IV and relocate it to another site.

The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the bestaction by the nurse at this time?

Discontinue the therapy and assess the client.

The husband of a client with terminal cancer is afraid of hurting his wife during sexual intercourse. Which action by the nurse is likely to be most helpful in reducing this client's fears?

Encourage discussion between the husband and wife regarding their intimacy needs

The nurse is preparing a presentation on preparing children for death. What information should the nurse include? Select all that apply.

Encourage expression of feelings. Provide for stability and safety. Talk openly about death and the feelings associated with it.

The client who is newly diagnosed with diabetes mellitus type 2 is concerned about eating products with sugar in them. What information does the nurse explain to the client regarding the use of sugar?

Excess sugar increases demand on the pancreas.

A terminally ill client told her family, "I am ready to die." Her family is very upset that she has given up and wants the nurse to intervene. Which nursing intervention is most appropriate?

Explain to the family that acceptance is part of the grieving process.

A client is to receive a blood transfusion. Immediately after initiating the transfusion, the nurse suspects that the client is experiencing a hemolytic reaction based on which finding? Select all that apply.

Fever Facial flushing Low back pain Hematuria

A nurse has applied a bandage to a client's arm from just above the wrist to just below the elbow. What finding(s) would suggest to the nurse that there are no circulatory complications? Select all that apply.

Fingers with quick capillary refill Warm hand No finger numbness or tingling

A nurse is teaching a class on holistic nutritional therapy to a group of young and middle-aged adults in the community. The nurse creates a menu of food and beverage choices and asks the group the select the best choices. The nurse determines that the teaching was successful when the group chooses which food? Select all that apply.

Fresh corn on the cob in season Organically grown chicken Bottled spring water

A client who is receiving chemotherapy and experiencing significant nausea asks the nurse about using aromatherapy to help alleviate the nausea. Which essential oil would the nurse most likely suggest to address the client's nausea?

Ginger

A client asks the nurse about the use of healing touch. Which statement regarding healing touch is accurate?

Healing touch does not use injections.

The wife of a client who has been diagnosed with a terminal illness asks the nurse about the differences between palliative care and hospice care. Which information would the nurse most likely include in the response?

Hospice care is provided for clients who have 6 months or less to live; palliative care is provided at any time during illness.

A nurse is caring for four different pediatric clients, all of whom require insertion of an intravenous (IV) catheter. For which client would it be appropriate to insert the IV into the foot?

Infant

The spouse of a client diagnosed with early memory loss asks about the use of ginkgo biloba as a dietary supplement. Which nursing assessment is essential prior to responding?

Is the client taking warfarin or aspirin?

The nurse is working with a client recently diagnosed with cancer. The client says, "I found this product that I want to use to fight my cancer." Which statements in the product literature should raise suspicion in the nurse? Select all that apply.

It contains a secret ingredient known only to the manufacturers. It cites personal testimony from a user that it cured her cancer. It claims to be an "all-natural" product. The pharmaceutical industry is trying to hide information about the product.

A nurse is providing wound care to a pressure injury that formed on the heel of a bedridden client several months ago. Which guideline should inform the nurse's practice?

It is appropriate to use clean technique during this procedure.

A nurse is applying healing touch to a postoperative client's wound. What benefit of healing touch should the nurse emphasize to the client's family?

It will help the wound heal.

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture?

Keep the swab and the inside of the culture tube sterile.

A nurse monitoring a client's IV infusion auscultates the client's lung sounds and detects crackles in the bases in lungs that were previously clear. What would be the most appropriate intervention in this situation?

Notify the primary care provider immediately for possible fluid overload.

The nurse is caring for a client whose blood type is B negative. Which donor blood type does the nurse confirm as compatible for this client?

O negative

An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations?

Offer small amounts of preferred beverage frequently.

A nurse is providing care to a client who is on fluid restriction. Which action by the nurse would be most appropriate?

Offer the client sugar-free candy to help combat thirst.

When assessing a person who is grieving using the grief cycle model, which concept would be most important for the nurse to keep in mind? Select all that apply.

People vary widely in their responses to loss. Stages occur at varying rates among people. Some people actually skip some stages of grief altogether.

The nurse is administering intravenous (IV) therapy to a client. The nurse notices acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Which complication related to IV therapy should the nurse most suspect?

Phlebitis

A nurse is caring for a client with quadriplegia. Which intervention by the nurse will prevent a heel or ankle pressure injury for the client?

Placing the client in a side-lying position with a pillow between the mattress and the lower leg, and a pillow between the lower legs

A client uses meditation as part of treatment for a neuromuscular disease. How can the nurse best facilitate continuation of this treatment while the client is hospitalized?

Provide a quiet uninterrupted period for meditation

Which principle does not encompass the basic goals of integrative medicine?

Reject allopathic medicine and embrace CAM practices.

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?

Remove the IV.

The nurse is certified in providing Therapeutic Touch and is preparing to initiate this for a client. What activity should the nurse perform first?

Requesting the client's permission to touch the body

Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take?

Rotate the swab several times over the wound surface to obtain an adequate specimen.

A nurse is assessing for the presence of edema in a client who is confined to bed and who often lies supine. The nurse would pay particular attention to which area?

Sacral area

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?

Start an IV of normal saline as prescribed.

During a blood transfusion of a client, the nurse observes the appearance of rash and flushing in the client, although the vital signs are stable. Which intervention should the nurse perform for this client first?

Stop the transfusion immediately.

A nurse at the health care facility cares for several clients. Some of the clients may require end-of-life care. Which case may require the service of a coroner?

The client did not have any recent medical consultation.

The nurse is preparing a packed red blood cell transfusion for a client. The nurse checks the client's blood type in the electronic medical record (EMR) and notes that it is blood type B. What does this mean?

The client has anti-A antibodies.

Which of these assessment findings indicate a positive outcome for a client after acupuncture?

The client reports a reduction in pain level to 3 out of 10.

A client asks about whether to consult a naturopathic physician for treatment. Which client factor would the nurse consider in determining the client would benefit from this consult?

The client states "I spend a lot of time watching television."

The home health nurse is visiting a client who has been living alone for the past 5 years following the death of the spouse. Which behavior suggests the client may be experiencing abnormal grief?

The client talks as if the loss just happened.

A nurse assessing client wounds would document which wounds as healing normally without complications? Select all that apply.

The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. a wound that does not feel hot and tender upon palpation a wound that forms exudate due to the inflammatory response

A nurse who has incorporated complementary and alternative medicine (CAM) into nursing practice is caring for a client in a short-term care facility. Which examples of nursing interventions are based on CAM? Select all that apply.

The nurse investigates herbs that may stimulate the client's immune system. The nurse encourages the client to join a yoga class. The nurse teaches the client how to meditate. The nurse uses guided imagery to relieve client anxiety.

A client who was injured when stepping on a rusted nail visits the health care facility. What is the most important assessment information the nurse needs to obtain?

The status of the client's tetanus immunization

A nurse who "unblocks" and "clears" congested areas of energy in a client's body to promote comfort is applying the phenomenon known as:

Therapeutic Touch (TT)

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples?

To splint the area when engaging in activity

A nurse is presenting an in-service program to a group of graduate nurses about blood component therapy. The nurse determines that the education was successful when the group identifies which complication as the primary cause of transfusion-related client death in the United States?

Transfusion-related acute lung injury

The nurse is assisting a client and family with the death and dying process. Which is the first thing the nurse does to prepare to provide culturally competent care?

Understand the client's beliefs.

A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn?

Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown

During a client interview, the client tells the nurse about using ginkgo biloba to improve memory. When reviewing the client's medication history, which medication if used by the client would be a cause for concern?

Warfarin

An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site?

a transparent film

A client is interested in losing weight but would like to use a holistic approach. To best achieve the weight loss through a holistic approach, what should the nurse discuss with the client?

adopt a diet that is primarily plant based

A client has recently lost a parent. The client spent about 6 months deeply mourning the loss and is just now able to function at the pre-loss level. During this process, a strong social support network was able to assist the client. What developmental stage of life does the nurse identify the client is in?

adult

A hospice nurse has developed a care plan for a client with liver cancer. The care plan focuses on providing palliative care for this client. The goal of palliative care is best described as providing clients with life-threatening illnesses a dignified quality of life through which means?

aggressive management of symptoms

How is control over the extracellular concentration of potassium within the human body is exerted?

aldosterone.

A nurse is caring for a client who has a 6 × 8-cm wound caused by a motor vehicle accident. The wound is currently infected and draining large amounts of green exudate. A foul odor is also noted. The wound bed is moist, with a yellow-and-red wound bed. Which dressing does the nurse anticipate is most likely to be ordered by the primary care provider?

alginate

What term is defined as "those practices that do not form part of the dominant system for managing health and disease"?

alternative medicine

A client suffers from chronic pain. The nurse suggests the client have monthly massages. This is an example of:

alternative medicine.

Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid?

an infant age 4 months

The nurse would recognize which client as being particularly susceptible to impaired wound healing?

an obese woman with a history of type 1 diabetes

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention?

applying sterile dressings with normal saline over the protruding organs and tissue

What is Kübler-Ross's third stage of grief?

bargaining

A widow develops cancer within 6 months of her husband's death. This may be a result of:

bereavement.

Potassium is needed for neural, muscle, and:

cardiac function.

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?

cardiac irregularities

Which is a common anion?

chloride

Upon admission, the nurse should give priority to addressing which need of a client who is displaying symptoms of dysfunctional grief?

coping strategies

A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor?

decreased blood volume and intracellular dehydration

A client is informed about the results of a biopsy, which indicate a malignant tumor that has spread. The client states, "Well once you remove the tumor, I will be just fine." What stage of the grief process does the nurse identify the client is experiencing?

denial

A terminally ill client is being cared for at home and receiving hospice care. The hospice nurse is helping the family cope with the client's deteriorating condition, educating them on the signs of approaching death. Which sign would the nurse include in this education plan?

difficulty swallowing

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):

durable power of attorney.

A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of:

electrolytes.

Edema happens when there is which fluid volume imbalance?

extracellular fluid volume excess

The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use?

figure-of-eight turn

A client is being discharged from the hospital with terminal brain cancer and a life expectancy of 1 month. When planning this client's discharge, it is most important for the nurse to include a referral to which agency?

hospice

Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume?

isotonic

The experience of parting with an object, person, belief, or relationship that one values is defined as:

loss.

A group of nursing students is reviewing information about body fluid and locations. The students demonstrate understanding of the material when they identify which of the following as a function of intracellular fluid?

maintenance of cell size

In the Parkes model, a person uses denial as a psychological defense in the stage of:

numbness.

The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths/min. Which arterial blood gas data does the nurse anticipate finding?

pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l)

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of:

phlebitis.

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?

placing the tourniquet on the upper arm for 2 minutes

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?

removing dead or infected tissue to promote wound healing

A decrease in arterial blood pressure will result in the release of:

renin.

On the advice of friends, a client on a palliative care unit has requested acupuncture. What it is the goal of this form of CAM?

restoring a healthy flow of energy along the meridians of the body

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a pale pink drainage on the dressing. Which drainage type should the nurse document?

serosanguineous

The children of a male client with late-stage Alzheimer disease have informed the nurse on the unit that their father possesses a living will. The nurse should recognize that this document is most likely to:

specify the treatment measures that the client wants and does not want.

The nurse is giving palliative care to a client with a diagnosis of COPD. What is the goal of palliative care?

to improve the client's and family's quality of life

Palliative care is a structured system for care delivery. What is its aim?

to prevent and relieve suffering

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as:

total parenteral nutrition.

A client has been receiving dialysis for years and now states, "I have been thinking about this for a long time. I no longer wish to continue dialysis. I just want to die." What is the most appropriate statement by the nurse?

"Can you tell me about why you've made this decision?"

The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate?

"Dehiscence is when a wound has partial or total separation of the wound layers."

When obtaining information for a database, which of the following represents a nurse commitment and interest in reflected integrative medicine (CAM)?

"Do you take any vitamins or minerals, and if so, what?"

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response?

"Fluid in the tissue space between and around cells."

When assessing a client, which statement indicates that the client is experiencing the anger stage of death and dying?

"I am a good person. Why did this happen to me?"

When reviewing a client's chart, the nurse notes that the client is in the disorganization stage of grief. Which assessment finding would support this diagnosis?

"I feel like I have absolutely no idea what to do next."

A client with end-stage chronic obstructive pulmonary disease (COPD) has reached the end of the 6-month period for hospice services and the family caregiver states, "I don't know what we will do if they cut off our hospice services." What is the best response by the hospice nurse?

"I will contact the health care provider to extend services since your family member meets the criteria."

A nurse has just finished a presentation on hospice and palliative care. Which statement by a participant would indicate a need for further education?

"In hospice care, the nurses make most of the care decisions for the clients."

A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate?

"Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein."

A nurse completing admission paperwork asks the client about having an advanced directive. The client states, "I do not know, what is an advanced directive?" What is the nurse's best response?

"It is a written document that identifies a person's preferences regarding which medical interventions to use in the event of a terminal condition."

The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response?

"Let me refer you to the blood bank so they can provide you with information."

The nurse is caring for a client who recently lost an older adult parent. Which client statement alerts the nurse that the stage of depression may have started within the grief process?

"Please go away; I just want to be left alone."

The nurse and client are looking at the client's heel pressure injury. The client asks, "Why does my heel look black?" What is the nurse's appropriate response?

"That is necrotic tissue, which must be removed to promote healing."

"My father has been dead for over a year and my mother still can't talk about him without crying. Is that normal?" What is the best response by the nurse?

"The inability to talk about your dad without crying, even after a year, is still considered normal."

The nurse is caring for a client diagnosed with pancreatic cancer. The client would like to use integrative care as a health care choice. What is the best response by the nurse?

"There are several alternative medicine modalities that could help with pain and relaxation during your treatment. I will get you some information on them."

The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include?

"Very little scar tissue will form."

The nurse is providing care to a group of terminally ill clients. The client who is most likely experiencing the anger stage of grief is the one who states:

"Why did this have to happen to me?"

A client asks the nurse for information about Traditional Chinese Medicine. The client specifically asks how Traditional Chinese Medicine might help manage one's chronic migraines. Which response by the nurse is best?

"Acupuncture uses fine needles inserted in the skin to stimulate natural painkillers and has proven to be beneficial in treating chronic migraines."

When the nurse is obtaining a health history on an elderly client who has had a previous myocardial infarction, the daughter states, "I have been giving my father ginkgo biloba every day, as he is beginning to have some memory loss." How does the nurse respond to the daughter's statement?

"How much of the herbal drug are you giving your father every day?"

The nurse in a medical unit is collecting a client's history and asks the client about the use of complementary and alternative therapies. The client asks why the nurse needs to know about this. What is the nurse's best response?

"It's important that we list all of your complementary health practices used to provide a full picture of what you do to manage your health.

A client asks the nurse about taking herbal medications. Which of these is the nurse's best response regarding safety of the herbal medications?

"Name brand products with herbal medications usually are of higher quality."

The nurse is caring for a client who recently found out he has a terminal illness. The nurse notes that the client is hostile and yelling. Which statement by the nurse shows that she has understanding of the Kübler-Ross emotional responses to impending death?

"Sometimes a person returns to a previous stage."

A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response?

"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound."

A client with stage IV colon cancer reports back pain and appears to be anxious. What response should the nurse provide when asked if therapeutic touch may be beneficial?

"Therapeutic touch is a holistic practice that works to redirect energy in the body and may help with pain and anxiety."

A client comes to the clinic for a routine visit. During the interview, the client tells the nurse, "I'd really like to try to use some herbs and supplements to stay healthy. Do you have any suggestions for what I should do?" Which response by the nurse would be appropriate? Select all that apply.

"Use products from reputable companies that have tested their quality." "Make sure to understand what you are taking and the reason why." "Learn about the product you are planning to use."

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate?

"Your wound will heal slowly as granulation tissue forms and fills the wound."

While assessing a client, the client tells the nurse that he is a follower of traditional Chinese medicine and the concept of qi. Based on the nurse's understanding of this concept, which treatment modality would the nurse expect the client to mention?

Acupuncture

A client is asking for the nurse to explain acupuncture. What would the nurse tell the client?

Acupuncture is used to correct disharmony.

The client is scheduled to receive dressing changes and warm soaks twice a day for an abscess to the lower extremity. The incoming nurse receives in the handoff report that the client has not been tolerating the dressing changes or warm soaks well due to acute pain. What action should the nurse take to promote client comfort and increase the effectiveness of the treatments?

Administer analgesics 30 minutes prior to the treatment to act on pain receptors.

A nurse is reading an online journal article about different approaches to health. The nurse is reading about a practice approach that is supported by evidence-based practice and is particularly effective when aggressive treatment is needed in an emergency situation. The nurse is reading about which type of approach?

Allopathic

A pediatric nurse is familiar with specific characteristics of skin across the life span. Which statement accurately describes skin characteristics?

An infant's skin and mucous membranes are easily injured and at risk for infection.

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client?

Dehiscence of the wound

The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing?

Fish

The nurse is caring for a client whose treatment has been based on the Ayurveda medical system. Which nursing intervention incorporates this client's beliefs into the nursing plan?

Helping the client to balance his or her dosha

A nurse is teaching a client experiencing stress about how relaxation helps to reduce the effects of stress on the body. Which underlying concept would the nurse integrate into the explanation about how relaxation works?

Helps to increase the effects of parasympathetic nervous system on the mind and body

A home care nurse delivers care that incorporates a philosophy that focuses on connections and interactions between parts of the whole. Which term best describes this philosophy?

Holism

The nursing instructor is discussing alternative therapy with a group of students. She explains that living organisms are "continuously connecting and interacting with their environment." Furthermore, the connecting and interacting signifies that the human body is a unified dynamic whole. The instructor is describing what theory to the students?

Holism perspective

Which of the following is a principle of Therapeutic Touch (TT)?

Human beings have natural abilities to transform and transcend their conditions of living.

The nursing instructor is discussing complementary and alternative medicine with a group of students. One of the students questions "What therapies are considered complementary and alternative medicine?" The instructor bases her response on her knowledge that which of the following are considered complementary and alternative therapies? Select all that apply.

Prayer Relaxation Qi gong Acupuncture

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon.

True

AA Penrose drain typically exits a client's skin through a stab wound created by the surgeon.

True

The husband of a client who has died cannot express his feelings of loss and at times denies them. His bereavement has extended over a lengthy period. What type of grief is the husband experiencing?

Unresolved grief

The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces?

a client sitting in a chair who slides down

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention?

a surgical incision with sutured approximated edges

A nurse wishing to learn about techniques of Therapeutic Touch (TT) is referred to a trained practitioner to observe the technique. While the practitioner is in the centering stage, which activity would the nurse most likely observe?

practitioner brings attention inward to a peaceful state of consciousness

The client, after undergoing an appendectomy for a ruptured appendix, has an open drain left in the wound. The health care provider prescribes removal of 2 in (5 cm) of drain every day. Which action will the nurse take?

reposition the safety pin or clip on the drain

A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site?

transparent

A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury?

use pillows to maintain a side-lying position as needed