Unit 2 Quiz

A nurse is assisting with the admission of a client to an inpatient unit. Which of the following sources of information should the nurse rely on for the most accurate information about the client? a. Client b. Family c. Medical history d. Progress note

Correct: a . Client Response Feedback: Information the nurse obtains directly from the client is generally the most accurate and provides the best information available. The client is a primary source of information.

A nurse is teaching an assistive personnel (AP) about using personal protective equipment while caring for clients. Which of the following statements should the nurse identify as an indication that the AP understands the instructions? a. "I will wear gloves whenever I am in contact with clients." b. "I will wear gloves and a gown when bathing a client who has open skin lesions." c. "I will wear gloves to minimize the number of times I have to wash my hands." d. "I will wear gloves when measuring a client's blood pressure."

Correct: b. "I will wear gloves and a gown when bathing a client who has open skin lesions" Response Feedback: The AP should wear personal protective equipment when in direct contact with a client's bodily fluids, such as gloves and a gown when coming in contact with wound exudate is possible.

A nurse notices an assistive personnel (AP) preparing to deliver a food tray to a client who practices the Orthodox Jewish faith. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take? a. Allow the AP to deliver the food tray to the client. b. Call the dietary department and ask for a kosher tray. c. Replace the nonfat milk with apple juice. d. Explain to the client that he needs the protein in the milk and the beef.

Correct: b. Call the dietary department and ask for a kosher tray Response Feedback: This action shows cultural sensitivity and respect for the client's cultural and spiritual beliefs. Clients who practice the Orthodox Jewish faith do not eat meat and dairy together.

A nurse in an outpatient clinic is assessing a middle adult client as part of a routine physical examination. The client's BP is 142/88 mm Hg, his body mass index (BMI) is 31, and he is a current smoker. The nurse should identify that this client has multiple risk factors for which of the following disorders? a. Testicular cancer b. Cardiovascular disease c. Depression d. Thyroid disease

Correct: b. Cardiovascular disease Response Feedback: Risk factors for cardiovascular disease include BP elevation, obesity, smoking, and a sedentary lifestyle.

A nurse is teaching a class on health promotion and illness prevention. The nurse should include that which of the following is an example of secondary prevention? a. Providing a community program on stress reduction b. Performing monthly breast self-examinations c. Teaching foot care to a client who has diabetes d. Referring a client who has had a mastectomy to a support group

Correct: b. Performing monthly breast self-examinations Response Feedback: Secondary preventive care focuses on early detection, such as with monthly breast self-examinations.

A nurse is caring for a client who has cancer and is receiving palliative care. Which of the following statements by the client indicates they understand this type of treatment? a. "I am thinking of getting a second opinion." b. "This treatment should help me live a little longer." c. "I am hoping this will limit my discomfort." d. "This is not working and I plan to stop treatment."

Correct: c. "I am hoping this will limit my discomfort" Response Feedback: Clients receiving palliative care are aware that the outcome is to prevent suffering and provide the best possible quality of life.

A nurse is completing the initial admission assessment and history for a client. Which of the following is the priority action for the nurse to take? a. Teach the client about his diagnosis. b. Provide a schedule of visiting hours to the client's family. c. Document the client's allergies in the electronic medical record. d. Develop a plan of care for the client.

Correct: c. Document the client's allergies in the electronic medical record Response Feedback: The greatest risk to this client is injury from incomplete or inaccurate documentation. Therefore, the first action the nurse should take is to document the assessment findings in the client's medical record. This will allow for continuity of care and reduces the risk for injury due to inaccurate documentation.

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take? a. Wear an N95 respirator mask. b. Wear sterile gloves. c. Wear clean gloves. d. Wear protective eyewear.

Correct: c. Wear clean gloves Response Feedback: The nurse should wear clean gloves to prevent the transmission of MRSA

A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understands when discharge planning should be implemented? a. "I will begin 48 hr before the client's discharge." b. "I will begin once the client's discharge order is written." c. "I will begin once the client's insurance company approves discharge coverage." d. "I will begin upon the client's admission to the facility."

Correct: d. "I will begin upon the client's admission to the facility" Response Feedback: Effective discharge planning must begin upon admission of the client to the facility.

A nurse is providing dietary teaching for a client who is Asian-American and is gazing at the floor during the instructions. Which of the following actions should the nurse take to demonstrate culturally sensitive nursing care? a. Stop the instructions to see what is on the floor. b. Emphasize the significance of the information. c. Move closer to the client for eye contact. d. Continue with the discussion

Correct: d. Continue with the discussion Response Feedback: A client from this culture might consider direct eye contact, close personal space, and touching to be impolite, aggressive, or disrespectful. By remaining silent and avoiding eye contact, the client could be demonstrating respect for the nurse. The nurse should continue with the dietary teaching while also avoiding eye contact and assess comprehension throughout the discussion.