EAQ 7

Which meal selection by a client on a 2-g sodium diet indicates that more diet teaching is needed?

Cottage cheese, crackers, relish, dish (celery, olives, sweet pickles)

Which is the priority intervention for the infant with developmental dysplasia of the hip?

Abduction of the hip

Which is appropriate for the nurse to include in the education of the ethical principal of nonmaleficence to a group of nursing students?

Act in ways to prevent harm to clients.

A client is scheduled for an adrenalectomy. Which action would the nurse expect in the plan of care?

Administer parenteral corticosteroids

Immediately after a subtotal gastrectomy, a client is admitted to the postanesthesia care unit (PACU). The nurse irrigates the nasogastric tube and observes small blood clots in the return. Which action would the nurse take?

Document this expected response.

In the team nursing model, which is a priority consideration when the team leader is assigning clients to team members?

Each team member's strengths

Which health care team member would the nurse expect could be delegated with the task of administering oral medication to a client per the functional model?

LPN

After teaching a family member how to administer subcutaneous enoxaparin sodium, how will the nurse evaluate the effectiveness of the training?

Observing the family member administering enoxaparin sodium to the client

Which action would the nurse take when administering eardrops to a 4-year-old?

Pull the auricle up and out

A group of individuals is working as a team in a rehabilitation program. Which nursing team member has the responsibility for acting as the team leader?

RN

Which health care professional is authorized to delegate work to other health care members?

RN

A child with acute spasmodic bronchitis who is receiving humidified air removes the mask, and while bathing the child the nurse notes increasing respiratory distress. Which is the most appropriate nursing intervention?

Stopping the bath and replacing the mask

When teaching a client with diabetes about monitoring for episodes of hypoglycemia, which symptom would the nurse include in the teaching plan?

Sweating

Which action would the nurse take for a client who is having a tonic-clonic seizure?

Taking measures to prevent injury

Which nursing action has the highest priority when preparing to transfer an unconscious client who sustained a head injury from the emergency department to a neurological trauma unit?

Validating availability of a bag-valve-mask during the transfer

Which tort involves intentional touching without the client's consent?

battery

Which delivery system was developed to provide care through others as an adaptation to functional nursing?

team

Which is the maximum recommended dose of an intramuscular injection in a toddler?

1 mL

A client is receiving patient-controlled analgesia (CA) after surgery. Which benefit would this type of therapy provide?

Client is able to self administer pain-relieving medication as necessary, decreases client, dependency, increases clients sense of autonomy

Which critical thinking skill is being used when the nurse apples knowledge and experience to client care? O Analysis O Evaluation O Explanation O Interpretation

Explanation

Which generation of nursing professionals, being exposed to both terrorism and natural disasters, would be key members for disaster planning initiatives?

Generation Y

Which action would the nurse take to help a female, bipolar client in the manic episode meet personal hygiene needs?

Guide her to dress appropriately in her own clothing

Which action would the nurse take for a client with schizophrenia who needs self-esteem increased?

Reward healthy behaviors.

Which right is applicable when the delegator and delegate understand a common work-related language? • Right of person • Right of supervision • Righty of circumstance • Right of communication

Right of communication

Which action would the nurse take for an adolescent with a long history of drug abuse, stealing, and refusal to comply with rules?

Serve as a role model for mature behavior, while providing a structured setting

A client has a tentative diagnosis of primary biliary cirrhosis. Which skin change would the nurse expect to observe when performing a physical assessment?

Telangiectasia is a vascular lesion associated with cirrhosis; it is thought to be related to increased estrogen levels.

Which action would the nurse take for a withdrawn client who suddenly screams, bursts into tears, and runs from the room to the far end of the hallway? Walk to the end of the hallway where the client is standing.

Walk to the end of the hallway where the client is standing

When questioning the staff about a change in the client's plan of care, which would the nurse demonstrate?

authority

Two hours after hip surgery, a client's vital signs are blood pressure 100/60 mm Hg, pulse 104 beats per minute, respiratory rate 22, and oxygen saturation 95%. Which action would the nurse take first?

check the dressing on the incision

Which is the critical factor among health care professionals, state agencies, and federal agencies to determine when and how to evacuate safely during a natural disaster?

communication

Which is the role of the nurse explaining the reason for the intravenous infusion and kit to the client?

educator

When providing care for a client with quadriplegia, which nursing intervention assists in decreasing the potential occurrence of pressure ulcers?

frequently reposition the client on a scheduled basis

Which cause of anemia would the nurse recognize as the most common cause of anemia in 1-year-olds?

iron deficiency

A health care provider informs a client that a T-tube will be in place after an abdominal cholecystectomy and a holedochostomy. Which would the nurse include in the preoperative teaching for this client regarding the primary reason why a T-tube is necessary?

keep common bile duct patent

Which member of the interprofessional team in a palliative care setting serves as the client advocate, evaluating the physical, emotional, and spiritual needs of the client?

nurse

In which role does the nurse oversee the budget of a specific nursing unit or agency?

nurse manager

Which education would the nurse provide the parent of a preschool child with atopic dermatitis?

scratching results in skin breaks that can lead to infection

When a client arrives in the emergency department after prolonged exposure to cold weather, which clinical manifestations will the nurse expect to find?

stupor, Paresthesia in affected body parts

A male client with ascites is to have a paracentesis and has signed the consent. While the nurse is caring for him, he says that he has changed his mind and no longer wants the procedure. Which response by the nurse is therapeutic?

tell me why you want to refuse the procedure?"

Which is the typical time line for a newborn to undergo cleft lip repair?

usually before the baby is 12 weeks old

The nurse is conducting discharge teaching with an adolescent with hemophilia. Which statement by the client indicates a need for further teaching?

"I'll use a straight razor when I start shaving."

The nurse is preparing to administer eardrops to a client who has impacted cerumen. Before administering the drops, the nurse will assess the client for which contraindications?

Allergy to the medication, Evidence of a fungal infection, Partial hearing loss in the affected ear

Immediately after a bilateral adrenalectomy, a client is receiving corticosteroids that are to be continued after discharge from the hospital. Which statement by the client indicates to the nurse that additional education is needed?

"I am glad that I only have to take the medication once a day."

Which client's plan of care cannot be delegated? A. Changing the client's position B. Assisting the client in walking C. Teaching care measures for a diabetic client D. Helping the client while bathing

C. Teaching care measures for a diabetic client

The nurse auscultates fine crackles in a client who has arrived in the emergency department with respiratory distress. When the nurse is providing information to the client about crackles, which is appropriate to include?

Crackles are located in the smaller air passages

According to Erikson's theory of psychosocial development, which is the correct order of a child's behavior as he or she ages?

1. The child develops autonomy by making choices. 2. The child develops feelings of superego or conscience. 3. The child concentrates on work and play. 4. The child is concerned about appearance and body image.

As a component of a client's routine physical examination, the nurse calculates the client's body mass index (BMI). The client's weight is 65 kg, and the height is 1.7 meters. What is the client's BMI? (Use 1 decimal place)

22.5

The nurse speaking in support of the best interest of a vulnerable client reflects which nursing duty?

Advocacy

Which advice would the nurse include in a teaching plan to reduce the side effects of diltiazem?

Change slowly from sitting to standing.

Which health care team member acts as a delegator in the absence of the registered nurse (RN)?

Charge nurse

The nurse plans to delegate some of the tasks for the discharge of a postpartum client to an unlicensed health care worker. Which activity must be performed by the nurse?

Comparing the identification bands of mother and infant

The nurse educator of a college health course is discussing tattoos with the class. Which type of hepatitis associated with tattoos would the nurse include in the teaching plan?

Hep C

For which clinical indicators would the nurse monitor when caring for a client with cholelithiasis and obstructive jaundice?

Dark urine, yellow skin, clay-colored stool

Which is the facility-level organizational model for disaster management?

Hospital Incident Command System (HICS)

A pharmacy technician arrives on the nursing unit to deliver opioids and, following hospital protocol, asks the nurse to receive the medications. The nurse is assisting a confused and unsteady client back to the client's room. How would the nurse respond to the technician?

I can't receive them right now. Please wait a few minutes or come back.

The registered nurse (RN) assigned a task to unlicensed nursing personnel (UNP). The UNP observed a change when measuring a client's blood pressure. Which action should the UNP take in this situation?

Inform the RN immediately

A client with hyperthyroidism is to receive methimazole. Which information would the nurse provide?

Initial improvement will take several weeks.

A client has cholelithiasis with possible obstruction of the common bile duct. Before surgery is scheduled, which consideration would the nurse make when determining the client's nutritional status?

Is the client deficient in vitamins A, D, and K?

Which education about the rationale for cranial radiation would the nurse provide the parents of a 3-year-old child who has acute lymphoblastic leukemia?

It prevents central nervous system involvement.

Which role would the unlicensed assistive personnel (UAP) have when caring for a client receiving intravenous (IV) therapy?

Monitoring clinical manifestations

Which finding would the nurse expect when assessing a client diagnosed with hypovolemic shock?

Oliguria

Which finding in a client with pulmonary edema requires the most rapid action by the nurse?

Oxygen saturation 82%

Which signs would alert the nurse that the client needs to take a break from practicing crutch walking?

Profuse diaphoresis and rapid respirations

When the nurse is assessing a client with laryngeal cancer who has had radical neck surgery, which finding requires the most rapid action?

Rapid oozing of blood and neck incision

Which intervention would the nurse include when developing a plan of care for a client in the manic phase of bipolar disorder?

Redirect the Kleins excess energy to more constructive activities

One month after abdominal surgery, a client is readmitted to the hospital with recurrent abdominal pain and fever. The medical diagnosis is fistula formation with peritonitis. The nurse would maintain the client in which position?

Semi-Fowler

Which education would the nurse provide about the occurrence of febrile seizures?

They may occur in minor illnesses

Which education would the nurse provide the parents of an infant with phenylketonuria (PKU) about the etiology of the condition?

This autosomal recessive disorder was inherited from parents who are carriers

Which would the nurse state to the mother of a toddler to promote safety?

Throw plastic grocery bags away

A client recovering from deep, partial-thickness burns develops chills, fever, flank pain, and malaise. Which prescribed diagnostic test would the nurse expect to confirm a tentative urinary tract diagnosis?

Urinalysis and urine culture and sensitivity

Which step in the nursing process would involve promoting a safe environment for the client?

implementation

Which parental statement would the nurse recognize as the appropriate application of time-out when disciplining a 4-year-old?

"explain the reason for the time out before and after disciplining him."

Which action would the nurse confirm before approving a client's transfer to radiology for magnetic resonance imaging (MRI)?

All metal objects, such as jewelry, hair, ornaments, and clothing containing metal were removed

Which children should be placed nearest the nurse's station upon admission?

An infant with acute laryngotracheobronchitis

The nurse is reviewing the history, physical examination, and diagnostic test results of a client with colitis. Which clinical findings are associated with this disorder? Select all that apply. Anemia Diarrhea Hemoptysis Abdominal cramps Decreased white blood cells

Anemia Diarrhea Abdominal

The nurse develops a plan of care for a client with an ileostomy and woul include which item?

Anticipate that any emotional stress can increase intestinal peristalsis.

Which type of play would the nurse encourage when providing age-appropriate care to a preschool-age child who is hospitalized?

Associative

Which action would the nurse take for a client with borderline personality disorder?

Be firm, consistent, and understanding while focusing on specific target behaviors.

The nurse providing immediate postoperative care to a client who had an abdominoperineal resection would assess for which clinical indicator of complications?

Bloody drainage on the abdominal or rectal dressings

The nurse on the medical-surgical unit tells other staff members, 'That client can just wait for the lorazepam; I get so annoyed when people drink too much.' Which does this nurse's comment reflect?

Demonstration of a personal bias

After a discectomy and fusion surgery, the client wants to attempt walking with assistance for the first time. Upon rising to a standing position, the client reports feeling faint and light headed. Which action would the assisting nurse have the client do upon hearing the client's concern?

Have the client sit on the edge of the bed so the nurse can hold the client upright.

Which action would the nurse take for a client who is a psychologist and has questioned the authority of the treatment team and advised other clients that their treatment plans are wrong?

accept that the client is unable to control this behavior while setting appropriate limits

Which would the nurse do while communicating with a group of adolescents? A. Ask adolescents open-ended questions. B. Avoid involving other individuals and resources. C. Avoid discussing sensitive issues such as sex and drugs. D. Be aware of clues about an adolescent's emotional state. E. Avoid looking for the meaning behind an adolescent's words or actions.

The nurse should ask adolescents open-ended questions. The nurse should be aware of clues about an adolescent's emotional state.

Which nursing behavior is essential when working with leadership personnel during the activation of the emergency preparedness plan?

collaboration

The nurse is teaching a client who had a thyroidectomy to observe for symptoms of surgically induced hypothyroidism. Which symptoms would be included in the teaching plan?

dry skin, lethargy, sensitivity to cold

A client is undergoing diagnostic testing for myasthenia gravis. Which test would the nurse identify as the most specific for this diagnosis?

edrophonium chloride test

The nurse is assessing a client with severe liver disease. Which assessment finding will the nurse expect to observe?

icterus

Which common complications of diabetes would the nurse assess for in a client with a long history of the disease?

leg ulcers, loss of visual acuity, prolonged capillary refill in the toes, decreased sensation in the lower extremities

A primary health care provider prescribes propylthiouracil (PTU) for a client with hyperthyroidism. Two months after being started on the medication, the client calls the nurse and complains of feeling tired and looking pale. Which action would the nurse take for this client?

schedule the client for an appointment

Which is the maximum volume of an intramuscular injection recommended for a preschool-aged child?

1.0ml

The nurse teaches the staff about the nasolacrimal duct. Which choice on the image below would the staff choose that indicates successful learning?

4

The nurse hears these sounds while auscultating a client's heart. Which abnormal sound would the nurse document for this client?

Fourth heart sound (S 4)

Which describes the role of the nurse in this situation when he or she informs the health care provider the client is requesting pain medication after surgery?

advocate

Which is the correct order of phases a client experiences in the event of a change in body image?

shock, withdrawal, acknowledgement, acceptance & rehabilitation

Tissue plasminogen activator (t-PA) is to be administered to a client in the emergency department. Before beginning the infusion, which assessment is the nurse's priority?

signs of bleeding

A client develops gastric bleeding and is hospitalized. Which area would the nurse assess most closely during the history?

Medications taken routinely or recently

Which client care activity may the nurse safely delegate to an unlicensed health care worker?

assisting a client who is recovering from an abdominal hysterectomy to the bathroom

While taking the blood pressure of a client with hypertension, the nurse hears the first Korotkoff sound at 128 mm Hg, then no sound is heard until the term-1manometer is at 110 mm Hg, and then Korotkoff sounds are heard until sounds disappear completely at 72 mm Hg. Which abnormal finding will the nurse document?

auscultatory gap

Which employee would be competent in critical thinking, leadership, communication, and time management skills?

charge nurse, registered nurse

Which mechanism of action explains how hydrochlorothiazide increases urine output?

increases excretion of sodium