251 Exam 2 PrepU Questions

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."

An older adult client tells the nurse, "I give myself a mineral oil enema every day." What is the appropriate nursing response?

"Mineral oil enemas can interfere with absorption of fat-soluble vitamins."

What is the normal urine output for catheterized clients?

Catheterized clients should drain a minimum of 30 mL of urine per hour

What is an activity that clearly exemplifies the evaluation step of the nursing process?

Checking the client's blood pressure 30 minutes after administering captopril

A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed, the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do?

Determine whether the prescribed treatment was effective

What is the advantage of using an external condom catheter for a male client who has frequent episodes of urinary incontinence?

It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters

A nursing responsibility in managing IV therapy is to monitor the fluid infusions and to replace the fluid containers as needed. What is an accurate guideline for IV management that the nurse should consider?

It is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the physician's order.

The nurse completed education with the client. Give an example of a documentation entry that represents the most complete teaching plan.

Printed and verbal information provided on gluten-free diet. Questions answered. Verbalizes understanding. Follow-up scheduled.

The nurse employs interpersonal skills of communication when caring for and interacting with clients. Which is the best example of establishing a therapeutic nurse-client relationship?

Show respect for the client, and engage in open communication in getting to know the client

A client who has been admitted to the hospital for the treatment of a gastrointestinal bleed requires a transfusion of packed red blood cells. Which aspect of the nurse's execution of this order demonstrates technical skill?

Starting a new, large-gauge intravenous site on the client and priming the infusion tubing

A code is called and Nurse A hands several drugs to Nurse B, stating while rushing off, "Give these to my client while I help with the code." What is Nurse B's appropriate response?

State, "I cannot give medications for other nurses."

A nurse needs to administer a prescribed dosage of antineoplastic drugs to a client with cancer. Which piece of medical equipment is used to administer antineoplastic drugs?

central venous catheter

The nurse cares for a client with a chronic neurological condition that decreases peristalsis. What nursing diagnosis is this client most at risk for?

constipation related to decreased peristalsis

A client is diagnosed with diabetes. The client's adult child offers to serve as an interpreter, because the client does not speak the dominant language. What is the best action for the nurse to take?

contact a professional interpreter

What is an example of a skill used in therapeutic communication?

controlling the tone of voice to avoid hidden messages

A nurse is scheduling diagnostic studies for a client. Which test would be performed first: fecal occult blood, barium study, or endoscopy?

fecal occult blood test

A client has been put on O2 therapy because of low O2 sat levels in the blood. What should the nurse use to regulate the amount of O2 delivered to the client?

flow meter

The nurse is preparing to administer an enteric-coated aspirin to a client. The client states, "I cannot swallow that so you will have to crush it and put it in applesauce for me as the other nurse does." Which is an appropriate reply from the nurse?

"Crushing the medication may cause the medication to irritate the stomach, so it must be swallowed whole."

The nurse is teaching a client about using two inhalers. What statement made by the client shows that the nurse's teaching is effective?

"I must wait at least 1 full minute between inhalers."

The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include?

"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."

The nurse is caring for a client at the end stage of life. The client is crying and states to the nurse, "I just cannot believe I am going to be leaving my children without a parent. I am not ready to go." What response by the nurse demonstrates the expression of empathy to the client?

"It sounds as though you are most concerned about how your children will feel."

The nurse is preparing discharge teaching for a client with a history of recurrent pneumonia. What deep breathing techniques will the nurse plan to teach?

"Take in as much air as possible, hold your breath briefly, and exhale slowly."

The nurse is teaching an 80 y/o 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."

The wife of a client who is terminally ill expresses to the nurse that she is unable to see her husband die and she may not come to the health care facility anymore. What should the nurse's response to her be?

"You have been coming here every day; are you taking some time for yourself?"

What is an example of something a home care nurse would say to her client who is measuring their peak respiratory flow rate at home?

"You will be asked to forcefully exhale into a mouthpiece."

What is a systematic way to form and shape one's thinking?

critical thinking

A 24-year-old woman was admitted to the hospital for an exacerbation of symptoms related to her cystic fibrosis. During a nurse's assessment of the client, the nurse notices a bluish color around her lips. What is the client exhibiting in this scenario?

cyanosis

A nurse has come on day shift and is assessing the client's intravenous setup. The nurse notes that there is a mini-bag of the client's antibiotic hanging as a piggyback, but that the bag is still full. The nurse examines the client's medication administration record (MAR) and concludes that the night nurse likely hung the antibiotic but failed to start the infusion. As a result, the antibiotic is 3 hours late and the nurse has consequently filled out an incident report. In doing so, the nurse has exhibited which type of skills?

ethical/legal skills

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

facial expressions

A nurse is preparing to teach a client about the importance of contraception and safe-sex practices. Which factors can most affect the nurse's teaching strategies for this client?

learning style preferences literacy level available resources

A nurse is caring for the client in a semi-private room. How will the nurse prepare a private environment to discuss the client's plan of treatment?

pull the curtain to divide the two beds

What term is most commonly associated with an acute UTI?

pyuria

What type of problem solving can be done within the nursing process?

scientific problem solving

When instructing the client regarding sublingual application, the nurse should inform that client that which action is contraindicated when using the drug?

swallowing the medication

The client reports to the clinic as ordered by the primary care provider for counseling on weight loss to improve overall health. The client received printed information in the mail to review before the session, and reports having read through it before the appointment. Which client statement alerts the nurse to a need for clarification and further education?

"I will be doing well if I lose between 5 and 10 lb (2.3 and 4.5 kg) per week."

Nurse A is having difficulty logging into the automated medication-dispensing system, and asks Nurse B to log in momentarily so that Nurse A is not delayed in administering client medications. What is Nurse B's appropriate response?

"I will get the hospital's information system's phone number for you."

The nurse is preparing to administer prescribed intravenous antibiotics to a client. While assessing the medication lock, the nurse notes that there is resistance when administering the saline flush solution. What would be the best action by the nurse?

Insert a new IV medication lock and remove the old one

A nurse refers a client with a new colostomy to a support group. Which aim of nursing is the nurse practicing?

facilitation of coping

A nurse at a health care facility provides continence training to a client. During the training, the nurse plans a trial schedule for voiding that correlates with the time when the client is usually incontinent. What is a possible reason for the nurse's action?

reduces potential for unintentional voiding

Self-evaluation is a method that nurses use to promote their own development and to grow in confidence in their nursing roles. This process is referred to as:

reflective practice

A nurse needs to administer a prescribed injection to an older adult client with impaired mobility. Which intramuscular site is preferred for administering an injection to older adult clients?

ventrogluteal

A nurse is assessing the stoma of a client with an ostomy. Which intervention should the nurse perform when providing peristomal care to the client to preserve skin integrity?

wash it with a mild cleanser and water

The client is reporting to the nurse that the continuous positive airway pressure (CPAP) mask is torture. How should the nurse respond?

"Tell me more about why it bothers you"

A client with urinary incontinence is prescribed incontinence briefs. Which factors should be included in the client education the nurse provides?

"Cleanse the skin each time you change the briefs."

The health care provider has recommended the client to have a surgical procedure performed. The surgery would allow the client's problem to resolve quicker. Without surgery, healing would be delayed. The client states, "I do not want the surgery done." What is an appropriate response by the nurse?

"Tell me the reason you do not want the surgery."

A client receiving home oxygen calls the telehealth nurse to report that her caretaker removed her oxygen tank from the wheeled carrier. What is the appropriate telehealth nurse response?

"The caregiver will need to place the oxygen tank back into the secure carrier."

A nurse is performing care for a PICC site. After cleaning the site and applying a new dressing and new injection caps, the nurse prepares to flush the catheter according to agency policy. Which size syringe would the nurse use?

10 cc

A client is administered an anxiolytic. Which nursing action demonstrates the nurse evaluating the client?

Asking whether the client feels less anxious 30 minutes after administering the medicine

The nurse must instruct a 35 y/o client with down syndrome about the use of an albuterol rescue inhaler. Give an example of documentation that 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

The nurse is caring for a client with a secondary urinary tract infection for which amoxicillin 250 mg PO has been prescribed. The nurse recognizes this as a drug that is routinely administered every 8 hours; however, the prescription does not state the frequency of administration. The health care provider is no longer present. What is the appropriate nursing action?

Contact the health care provider to clarify the prescription by reading back to the provider, update the electronic medical record (EMR) while on the phone, then document it was a phone prescription.

A nurse is caring for a client with an external condom catheter. What guideline should be implemented when applying and caring for this type of catheter?

Fasten the condom securely enough to prevent leakage without constricting blood flow

A client recently received 2 units of packed red blood cells. Which laboratory result below demonstrates that the blood transfusion was successful?

Hemoglobin level 15 g/dL (150 g/L)

When teaching a nursing student to administer an influenza vaccine, which is the "right route" the student nurse determines to be correct?

IM

An emergency room nurse is ordered to administer nitroglycerin to a client being treated for acute pulmonary hypertension. Which means of drug administration would the nurse use to achieve rapid results in this emergency situation?

IV infusion

A nurse is caring for a client who sustained head trauma. The client is in a medically induced coma and on mechanical ventilation. The client's parent is at the bedside in tears. The parent states, "I just want my child to know I am here." To address the needs of the parent and the client, what would be the nurse's most appropriate response?

Place a chair next to the bed and encourage the parent to hold the client's hand

The nurse is assessing a client who was seen 7 days ago with strep throat. The client states, "I felt better after 2 days of the antibiotic the provider prescribed, so I quit taking it." What would the nurse do to address this situation?

Provide education on taking all antibiotics for effective treatment

Rights of Medication Administration

Right medication Right patient Right dosage Right route Right time Right reason Right assessment data Right documentation Right response Right to education Right to refuse

The nurse reviews information about defecation with a group of nursing students in preconference prior to their clinical experience for the day. What response by the students indicate that the information given by the nurse is understood?

The center in the medulla and another center in the spinal cord govern the reflex to defecate

The nurse meets with the client to teach self-administration of low molecular weight heparin. During the initial part of the training the client shakes the head and asks the nurse to repeat the instructions. What action demonstrates that the nurse has assessed the client's communication abilities?

The nurse faces the client, speaks slowly and clearly, and demonstrates the procedure using a needleless syringe

A nurse who is caring for newborn infants delivers care by utilizing the sense that is most highly developed at birth. Give an example of nursing care that achieves this goal

The nurse gently strokes the baby's cheek to facilitate breastfeeding

Which assessment should be conducted by the nurse before she administers tuberculin intradermal injection?

checking for documented allergies to food or drugs

While working as part of an interdisciplinary group developing a client's plan of care, a nurse asks the question, "Can you give me an example?" The nurse is demonstrating which standard for judging thinking?

clarity

A client scheduled for a colonoscopy is scheduled to receive a hypertonic enema prior to the procedure. A hypertonic enema is classified as which type of enema?

cleansing enema

A sterile urine specimen for culture and sensitivity has been prescribed for a client who has an indwelling urinary catheter. How should the nurse obtain this specimen?

Withdraw several milliliters of urine from the port on the collection tubing, using aseptic technique.

Give an example of a client likely to require interventions in order to maintain regular bowel patterns

a client whose neuropathic pain requires multiple doses of opioids each day

What learning domain is a nurse demonstrating by instructing a client to tell the nurse about the side effects of a medication?

cognitive

A unit-based infection control task force was developed in an attempt to reduce catheter-acquired infections. The group consists of 10 team members. During the past three meetings, one person dominated the meeting and did not allow other members ample time to speak. The best way to address the team dysfunction is to

have group members confront the dominant member to promote the needed team work.

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. Give an example of a statement made by the nurse to verify the report from the paramedic?

"All of the people got themselves out of the car?"

A client was recently diagnosed with metastatic lung cancer. The nurse finds the client crying in the room. What is an example of a statement made by the nurse that best demonstrates the use of empathy?

"I see you are upset. Would you like to talk?"

What is a response given by a client enables the nurse to determine the effectiveness of a recent medication teaching session for an older adult client who is diagnosed with tuberculosis?

"I will be taking the TB medication for at least 6 months, because it takes a long time to kill the TB germs."

The nurse just completed a refresher course on parenteral drug administration. What statement by the nurse indicated the teaching was effective?

"Reconstitution is the process of adding liquid, known as diluent, to a powdered substance."

A nurse is assessing a client's nutritional intake. Prior to admission, the client has lost 10 lb (4.5 kg) over the last 2 months. Which example best represents therapeutic communication technique?

"Tell me about the type of foods you like to eat."

A client with no significant medical history reports experiencing diarrhea over the past week. Which assessment question(s) will the nurse ask?

"What are your normal bowel habits?" "Do you use laxatives?" "Have you started a new medication?"

The nurse has been working with a client for several days during the client's recovery from a femoral head fracture. Give an example of how the nurse can best evaluate whether client teaching regarding the prevention of falls in the home has been effective

"What changes will you make around your house to reduce the chance of future falls?"

A nurse is trying to encourage a client with paraplegia who is depressed and not adhering to the treatment program to join a support group. Give an example of an appropriate statement the nurse can make

"What do you know about support groups?"

A nurse is preparing to administer IV therapy to a client and selects a catheter with a large lumen. Which catheter would have the largest lumen: 18, 20, or 22 gauge?

18 gauge

A nurse assesses the vital signs of a healthy newborn infant. Based on the developmental level of this client, what is the expected respiratory rate?

30-60 breaths/minute

A nurse is administering total parenteral nutrition (TPN) solution to a severely dehydrated client at the health care facility. Which nutrient would the nurse identify as a carbohydrate source?

50% dextrose solution

A client could experience increased urination when using which classification of medication?

Cholinergic agents

A client asks, "Why do some foods, like corn, come out undigested in my feces?" What is the nurse's best response?

Corn is high in cellulose, which is an insoluble fiber that the body cannot digest.

The parents of a school-age child are meeting with the nurse for health promotional education for their child. The child has the following assessment data: a 7-year-old male with diabetes mellitus type 1 with a hemoglobin A1C level of 8.3%, a body mass index (BMI) of 31.7, and a BMI percentile of 99. What are the most appropriate learning diagnoses for this first session?

Deficient Knowledge: Imbalanced nutrition: more than body requirements, and ineffective health maintenance.

The nurse is preparing to auscultate the bowel sounds of a client with an NG tube in place set to low intermittent suction. How shall the nurse approach the assessment of bowel sounds and manage the NG tube?

Disconnect the nasogastric tube from suction during the assessment of bowel sounds

The nurse is providing care to an older adult client who has visual and hearing deficits. What action by the nurse is appropriate to help with communication?

Identify oneself by name and title with each entry into the client's room.

The nurse is assessing a client who reports being constipated. Which assessment data confirm the client report?

The client has a distended, hard abdomen. The client reports fullness in the rectum.

A nurse during orientation notices that the preceptor gives all subcutaneous injections on a 45-degree angle. When the new nurse asks the preceptor the rationale for the practice the preceptors states, "This is how I do it, and this is how you will do it." The new nurse recognizes this behavior to be

aggressive

A client diagnosed with anemia is receiving a blood transfusion. The client develops urticaria accompanied by wheezing and dyspnea not long after the transfusion starts. The nurse interprets this as indicative of

allergic reaction

List the steps of the nursing process in order

assessment diagnosis planning implementation evaluation

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. What is an example of an intervention the nurse would include in the teaching plan to address the psychomotor domain?

demonstrating the technique for insulin self-administration

A nurse is designing an education program for individuals who have recently immigrated from Iraq. What would be an example of a culturally competent patient education?

developing written materials in the client's native language

What is a characteristic of person-centered care?

it is a framework for providing care

True or false: Use of an indwelling urinary catheter leads to the loss of bladder tone

true People with indwelling urinary catheters lose bladder tone because the bladder muscle is not being stretched by the bladder filling with urine. During prolonged periods of immobility, decreased bladder and sphincter tone can result in poor urinary control and urinary stasis.

Critical thinking is important in making an effective nursing judgment. Which technique would be most effective for the nursing student to adopt to improve classroom success?

turn errors into learning opportunities

A nurse is assessing the urine in a newborn's diaper. What would be the normal assessment finding?

urine is light in color and odorless

The nurse is providing health teaching for four clients. Which client should consider a colonoscopy screening?

50-year-old client with a family history of polyps

A client is ordered 1000 mL 5% dextrose and normal saline to infuse over 12 hours. When setting up the electronic infusion device, the nurse would set the device to deliver how many milliliters of fluid per hour?

83

The nurse is preparing to administer insulin to an obese client. At what angle should the nurse plan to insert to needle into this client?

90 degrees

A client is receiving supplemental oxygen and the nurse is monitoring the client's oxygen saturation level using pulse oximetry. The nurse notifies the physician if the client reaches which oxygen saturation level?

92%

A nurse at a healthcare facility needs to administer an otic application for a client with an earache. What should the nurse do after instilling the prescribed eardrops in the client's ear?

ask the client to maintain the same position for some time

A nurse is caring for an older adult client. What strategy should the nurse utilize to confirm the client's understanding of instructions?

ask the client to repeat the instructions

The health care provider has prescribed an indwelling catheter for a client. When the nurse explains the procedure, the client refuses to allow placement of the catheter. Which action should the nurse take?

ask the client why he or she does not want the catheter

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

A client has an intermittent infusion device inserted for the administration of antibiotic therapy every 6 hours. The nurse would expect to flush the device at which frequency?

before and after each medication administration

What is fecal occult blood?

blood in the feces that cannot be seen

The nurse uses evidence-based practice findings in the development of a care plan. What type of nursing skill is this an example of?

cognitive skill

A client with a history of advanced liver disease comes to the emergency department (ED) with dehydration. White blood cell count shows elevation in bands and neutrophils. When preparing to catheterize the client, what color urine does the nurse anticipate will drain?

dark brown and cloudy

What does the nurse expect to be included in the directions for reconstitution on a drug label?

directions for storing the drug amount of diluent to be added dosage per volume after reconstitution

The client is newly diagnosed with type 2 diabetes. After teaching the client about diabetes and how to self-administer insulin, the nurse identifies which client response as a need for further education?

during the return demonstration, the client draws up insulin, leaving tiny bubbles in the syringe

A nurse is caring for a client who is being treated for a bladder infection. The client reports to the nurse that he has been having difficulty voiding and feels uncomfortable. How should the nurse document the client's condition?

dysuria

True or false: The appearance of urine streaked with blood is ALWAYS abnormal

false Urine may appear cloudy, dark reddish-brown, or streaked with blood when a woman is menstruating.

The nurse is conducting a respiratory assessment of a client age 71 years who has been recently admitted to the hospital unit. What is an example of an abnormal finding?

fine crackles to the bases of the lungs bilaterally

A nurse is performing the Heimlich maneuver on a young client to relieve a mechanical airway obstruction. What action by the nurse will increase intrathoracic pressure?

give five quick abdominal thrusts above the navel

The nurse is providing discharge teaching for an older adult with arthritis who also has an implanted catheter. Which care does the nurse anticipate the client will need to provide catheter care?

home care

A client is being started on total parenteral nutrition (TPN). When initiating the therapy, the nurse gradually tapers up the infusion rate as ordered to prevent which potential complication?

hyperglycemia

Upon evaluation of a client's medical history, what is something that the nurse recognizes as a possible symptom of chronic anemia?

inadequate supply of oxygen to the tissues of the body

What is a strategy a nurse might use to increase compliance with education?

including the client and family members as partners

A client with terminal cancer is taking high doses of an opioid for pain. Which comfort measures should the nurse teach the client's family regarding how to manage elimination care?

increase fiber in the diet

A client is receiving IV therapy with an isotonic solution. The nurse notes swelling and coolness at the site along with an absent blood return. Which of the following would the nurse suspect?

infiltration

A client has had a tracheostomy and the nurse is prepared to conduct tracheostomy care. What part of the tracheostomy is removed for cleaning?

inner cannula

A client presents to the emergency room reporting weight gain, respiratory crackles, productive cough, and shortness of breath. The nurse demonstrates the implementation phase of the nursing process by performing which action?

inserting a peripheral IV and urinary catheter

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

What type of thinking is critical thinking?

it is a systematic way of thinking

The nurse is working with a client who requires continence training. Which client teaching about pelvic floor muscle exercises (Kegel exercises) will the nurse include?

keep the muscles contracted for at least 10 seconds

A nurse has an order to obtain a sputum specimen on a newly admitted client. Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?

label the specimen and bring it to the lab

A nurse is administering a prescribed solution of cottonseed oil to a client during an enema. What is the outcome of the use of cottonseed?

lubricates and softens stool

The nurse is providing care to a client who has a Groshong catheter inserted. When irrigating the catheter, the nurse would use which solution?

normal saline

What nursing action is applicable to the psychomotor domain of learning when conducting a teaching session for breastfeeding mothers?

observing the mother expressing the breast milk

A male client has always prided himself in maintaining good health and is consequently shocked at his recent diagnosis of diabetes. The nurse has asked the client, "How do you think your diabetes is going to affect your lifestyle?" The nurse has utilized which interviewing technique?

open-ended questions

The nurse observes that the client's pulse oximetry is 89%. What is the priority nursing action?

perform a respiratory assessment

A nurse is educating a home care client on how to do pursed lip breathing. What is the therapeutic effect of this procedure?

prolongs expiration to reduce airway resistance

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

psychomotor

While providing care to a client admitted to the health care facility, the client states that she has "a burning sensation when urinating." After further questioning, the nurse inspects the client's perineal area. What would the nurse document as an abnormal finding?

reddened meatal skin

The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order?

residual volume

The nurse is caring for a client with a chest tube. Which assessment finding indicates that the tube is functioning correctly?

respirations are at 20 breaths per minute

The nurse has provided teaching for a client with a sinus infection who has been prescribed antibiotics and a decongestant. The client states, "I'm not sure how many days I'm supposed to take this antibiotic." What is the nurse's appropriate response?

reteach the length of time to take the medication

A client is experiencing difficulty in adjusting to a new prosthesis despite conscientious client education by numerous members of the healthcare team. How should the team respond to the client's lack of learning to this point?

revise the education plan that has guided education

A nurse is preparing an intravenous infusion. Which part of the administration set would the nurse use to manually regulate the infusion rate?

roller clamp

A nurse is assisting a client when he is draining a continent ileostomy. The catheter suddenly becomes plugged with stool. Which action should the nurse take to rectify the problem?

rotate the catheter tip inside the stoma

The nurse is reviewing the plan of care for a client who has a newly placed implanted catheter and is to be discharged home. What is a priority for the nurse to include in the plan of care?

signs of infection

The nurse is caring for an older adult client with diarrhea. Which assessment finding requires immediate nursing intervention?

skin turgor response 5 seconds

A client is receiving a secondary infusion of a new antibiotic. After 5 minutes of administration, the client reports itching and appears flushed. What is the first nursing intervention?

stop the infusion immediately

Which catheter would the nurse use to drain a client's bladder for short time periods (5-10) minutes?

straight catheter

A 70-year-old client who has four children and six grandchildren states that she "wets" herself when she sneezes or laughs. She reports that sometimes this also occurs when rising from a sitting to standing position. Which type of incontinence does the nurse anticipate?

stress incontinence

A nurse working in a community peds clinic explains the process of toilet training to mothers of toddlers. What is a recommended guideline for initiating this training?

the child should be able to communicate the need to void

The nurse is preparing to administer a transdermal medication. How should this be accomplished?

the nurse should apply the medication directly to the skin

The nurse enters a client's room after receiving a morning report. The nurse rapidly assesses the client's airway, breathing, and circulation and greets the client by saying "Good morning." The client makes no reciprocal response to the nurse. How should the nurse best respond to the client's silence?

the nurse should ask appropriate questions to understand the reasons for the client's silence

A postoperative client's medication administration record (MAR) provides for PRN administration of a number of analgesics by various routes. Which action should the nurse take to assess the client's pain to determine the appropriate analgesic to administer?

the nurse will have the client rate their pain on a scale from 1 to 10 and proceed accordingly

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:

the outcome

Many members of the staff on a hospital unit are critical of a client's family, who has different cultural beliefs about health and illness. A new nurse assigned to the client, however, does not agree with the other members of the staff, based on the nurse's own experience in caring for the client and family. Which critical thinking attitude is the nurse demonstrating?

thinking independently

What is the best explanation from the nurse as to why a client must return to the unit in 48 hours after having a tuberculin skin test intradermal?

to determine the extent to which the client responded to the drugs

A client with an infection is receiving intravenous antibiotic therapy. The client has an intermittent infusion device in place. The nurse flushes the device with normal saline solution before administering the antibiotic based on which rationale?

to prevent blood clot formation

What is the most important reason for the nurse to develop critical thinking and clinical reasoning?

to provide quality care with nursing ability and knowledge

The nurse is caring for a client who has had a percutaneous tracheostomy (PCT) following a motor vehicle accident and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client?

tracheostomy collar

A nurse is providing education to a client who is scheduled for a cystoscopy as an outpatient procedure. Which description would the nurse include when discussing this procedure?

use of a flexible tube that is guided into the bladder

A client has received nursing teaching about proper skin care at a stomal site. The nurse's teaching has been effective when the client identifies which solution is used to clean the stoma?

water and mild soap

A nurse is assessing the stools of a breast-fed baby. What is the appearance of normal stools for this baby?

yellow, loose, odorless