AEQ's Basic care

Which action for nutritional needs would the nurse take for a depressed client who has been sitting alone in a chair most of the day and displays no interest in eating?

Stay with the client during meals.

The nurse who is working on a medical-surgical unit receives a phone call requesting information about a client who has undergone surgery. Which response by the nurse is best?

"It is against the hospital's policy to provide you with any information."

Which questions would the nurse initially ask to conduct a culturally competent assessment interview? Select all that apply.

"Can you tell me about the reasons for coming here today?" "What do you believe is the cause of your depression?" "Does religion have a role in your perception of health and wellness?" "Have you ever sought treatment for a mental health problem before?

A client has an adenocarcinoma of the colon with suspected metastasis. The nurse provides education about the liver computed tomography (CT) scan with contrast medium that is prescribed. Which statement made by the client indicates that the teaching is effective?

"Before the procedure, I will receive an intravenous [IV] infusion and, during the procedure, I must lie as still as possible for a period of time."

Which statement made by the client would the nurse consider to be an external variable influencing the client's beliefs?

"Please do not include chicken in my diet plan because my religion forbids me to consume meat."

A client has an abdominoperineal resection. Which position would the nurse encourage the client to assume to promote perineal wound healing? Modified left lateral recumbent Side-lying Knee-chest Dorsal recumbent

Side Lying

When caring for a client who has just arrived in the emergency department with possible acute coronary syndrome, which prescribed action would the nurse take first?

Ask the client about the level of intensity of the chest pain

Which is the best action for the nurse to take when a client with hypertension tells the nurse, "I took the blood pressure pills for a few weeks, but I didn't feel any different, so I decided I'd only take them when I feel sick"?

Ask the client questions to determine the current understanding of high blood pressure

Which action would the nurse take when caring for a neonate that weights 1.8kg and whose birth parent is Hepatitis B negative?

Administer HepB vaccine to the newborn 1 month after birth

Which problem would be the most difficult for the nurse to manage when meeting the needs of an extensively burned client 3 days after admission?

Changing and debriding wounds to prevent Infections

After a cholecystectomy to remove a cancerous gallbladder, a client has a T-tube in place. The T-tube drains 300 mL of bile-colored fluid during the first 24 hours after surgery. Which action would the nurse take? Clamp the tube intermittently to slow the drainage. Increase the rate of intravenous fluids to compensate for this loss. Empty the portable drainage system and reestablish negative pressure. Consider this an expected response after surgery and record the results.

Consider this an expected response after surgery and record the results

Which action would the nurse take first after noting stridor in a client who just arrived in the postanesthesia care unit (PACU) after receiving a general anesthetic?

Notify the health care provider

The nurse provides education for a client with cirrhosis of the liver who has a prolonged prothrombin time and a low platelet count. A regular diet is prescribed. Which instruction would the nurse include in the teaching? Report signs of bleeding no matter how slight.

Report signs of bleeding no matter how slight.

Which finding by the nurse would require rapid action when a client with chest pain is having an exercise electrocardiogram (ECG)?

ST-segment depression

A registered nurse is teaching a nursing student about the importance of values in nursing practice. Which information provided by the registered nurse is appropriate?

"Values vary among clients and develop and change over time." "The values that an individual holds reflect cultural and social influences." "To discuss differences in opinions and values, the nurse should be clear about his or her own values."

Which response is most therapeutic to give to an older client who is angry at her daughterin-law because "She doesn't understand me; she's not from our culture"?

"You would like her to try to see your point of view."

A client says, "None of the medications will work on me because I am away from my holy land." Which course of action would the nurse take to comply with teamwork and collaboration competency according to the Quality and Safety Education for Nurses (QSEN)?

Approach the agency chaplain to discuss the spiritual needs of the client.

Which purposes are accomplished by applying the four elements of safety, critical thinking, stability, and time in the delegation of tasks? Select all that apply. One, some, or all responses may be correct.

Assessing the ability of unlicensed nursing personnel (UNP) to perform the taskEncouraging effective delegation decisionsEnsuring effectiveness in performing elements of care

Which response would the nurse have for the parent of a school-age child who expresses concern that the child appears thinner than in years prior?

Body fat diminishes and distribution changes during this stage of development

Which scenarios are examples of slander? Select all that apply. One, some, or all responses may be correct.

Informing the client's caregivers that the client is aggressive, even though there is no evidence Warning a colleague that a client displays inappropriate sexual behavior when no such event happened Informing the primary health care provider falsely that a client shows signs of drug abuse

A client develops a gallstone that is lodged in the common bile duct and is scheduled for an endoscopic sphincterotomy. The nurse provides education about the surgery and includes information about which type of anesthesia?

Intravenous Sedatives

Which action would the nurse take next after cardiopulmonary resuscitation has been started by the code team for an unresponsive hospitalized client?

Obtain the defibrillator and place paddles on the client's chest.

Which information would the nurse include when teaching a client with coronary artery disease about aspirin therapy? Select all that apply. One, some, or all responses may be correct.

Take aspirin with food. Report ringing in the ears. Monitor and report excessive bleeding and bruising. Avoid over-the-counter pain medications that contain aspirin.

Which immediate nursing intervention is most likely to increase anxiety for a client who is increasingly agitated?

Teaching Relaxation

"Which action further develops trust among the members of a therapy group?

The need for confidentiality of group members disclosures is discussed

A registered nurse is caring for a client according to the total client care model of nursing. Which activity performed by the nurse manager would be appropriate in this situation? Select all that apply. One, some, or all responses may be correct.

Weighing the expenses of a registered nurse vs LPN Deciding the type of care provided by nursing assistive personnel

The nurse is delegating care for a client with diabetes mellitus to another health care team member. Which instruction, if given by the nurse, would best reflect the selling relationship with the delegatee?

You will provide care to the client with diabetes and I will show you where to record the blood glucose level