Evolve Fundamentals

While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the nurse take?

Lower the height of the enema bag

Alternative therapy measures have become increasingly accepted within the past decade, especially in the relief of pain. Which methods qualify as alternative therapies for pain?

Prayer, hypnosis, aromatherapy, guided imagery

A nurse is caring for a client on bed rest. How can the nurse help prevent a pulmonary embolus?

Teach the client how to exercise the legs.

Health promotion efforts within the health care system should include efforts related to secondary prevention. Which activities reflect secondary prevention interventions in relation to health promotion?

Encouraging regular dental checkups, teaching the procedure for breast self-examination

A nurse is supportive of a child receiving long-term rehabilitation in the home rather than in a health care facility. Why is living with the family so important to a child's emotional development?

It is where child's identity and roles are learned

A nurse who is working on a medical-surgical unit receives a phone call requesting information about a client who has undergone surgery. The nurse observes that the client requested a do not publish ("DNP") order on any information regarding condition or presence in the hospital. What is the best response by the nurse?

"We have no record of that client on our unit. Thank you for calling."

The nurse instructs a client that, in addition to building bones and teeth, calcium is also important for:

Blood clotting

What is a nurse's responsibility when administering prescribed opioid analgesics?

Count the client's respirations, document the intensity of the client's pain, verify the number of doses in the locked cabinet before administering the prescribed dose

A client is admitted to the hospital for an elective surgical procedure. The client tells a nurse about the emotional stress of recently disclosing being a homosexual to family and friends. What is the nurse's first consideration when planning care?

Identifying personal feelings toward this client

What is a basic concept associated with rehabilitation that the nurse should consider when formulating discharge plans for clients?

Immediate or potential rehabilitation needs are exhibited by clients with health problems.

Which age-related change should the nurse consider when formulating a plan of care for an older adult?

Increased sensitivity to glare & diminished sensation of pain

A nurse is providing preoperative teaching for a client regarding use of an incentive spirometer and should include what instructions?

Inhale deeply through the spirometer, hold it as long as possible, and slowly exhale

A nurse is preparing to change a client's dressing. What is the reason for using surgical asepsis during this procedure?

Keeps the area free of microorganisms

A nurse is preparing to administer an oil-retention enema and understands that it works primarily by:

Lubricating the sigmoid colon and rectum

When reviewing a drug to be administered, the nurse identifies that the package insert indicates that the Z-track injection technique should be used. Under what circumstance does the nurse expect that this technique will be necessary?

Medication is irritating to subcutaneous tissue and skin.

A nurse assesses the vital signs of a 50-year-old female client and documents the results. Which of the following are considered within normal range for this client?

Oral temperature 98.2° F, Apical pulse 88 beats per minute and regular, Blood pressure 116/78 mm Hg while in a sitting position

What is the most important factor relative to a therapeutic nurse-client relationship when a nurse is caring for a client who is terminally ill?

Personal feelings about terminal illness

A client undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock?

Restlessness

When caring for a client with varicella and disseminated herpes zoster, the nurse should implement which types of precautions?

Standard, airborne, contact

While receiving a preoperative enema, a client starts to cry and says, "I'm sorry you have to do this messy thing for me." What is the nurse's best response?

"You seem upset."

A nurse assesses a client with dry and brittle hair, flaky skin, a beefy-red tongue and bleeding gums. The nurse recognizes that these clinical manifestations are most likely a result of:

A nutritional deficiency.

A nurse is caring for a client admitted with cardiovascular disease. During the assessment of the client's lower extremities, the nurse notes that the client has thin, shiny skin, decreased hair growth, and thickened toenails. The nurse understands that this may indicate:

Arterial Insufficiency

The nurse is teaching a client about adequate hand hygiene. What component of hand washing should the nurse include that is most important for removing microorganisms?

Friction

What should the nurse consider when obtaining an informed consent from a 17-year-old adolescent?

If the client is allowed to give consent

Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus?

Impaired neural functioning

The nurse is caring for a client who is on a low carbohydrate diet. With this diet, there is decreased glucose available for energy, and fat is metabolized for energy resulting in an increased production of which substance in the urine?

Ketones

A health care provider prescribes transdermal fentanyl (Duragesic) 25 mcg/hr every 72 hours. During the first 24 hours after starting the fentanyl, what is the most important nursing intervention?

Manage pain with oral pain medication

What clinical finding indicates to the nurse that a client may have hypokalemia?

Abdominal distention

The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer's dementia. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen the client is to take medications six times throughout the day. What is priority nursing intervention to assist the client with compliance with medication-taking?

Contact the primary healthcare provider and discuss the possibility of simplifying the medication regimen.

The nurse is caring for a client with a closed soft tissue injury. The nurse describes the injury as a/an:

Contusion

A client, who is in a late stage of pancreatic cancer, intellectually understands the terminal nature of the illness. Behaviors that indicate the client is emotionally accepting of impending death are that the client is

Revising the client's will and planning a visit to a friend

An adolescent that had an inguinal hernia repair is being prepared for discharge home. The nurse provides instructions about resumption of physical activities. Which statement by the adolescent indicates that the client understands the instructions?

"I can't perform any weightlifting for at least 3 weeks."

A nurse suspects that a client has poison ivy. Assessment findings reveal vesicles on the arms and legs. A vesicle can be described as:

A lesion filled with serous fluid

A female client explains to the nurse that she sleeps until noon every day and takes frequent naps during the rest of the day. What should the nurse do initially?

Arrange a referral for a thorough medical evaluation

After abdominal surgery a client reports pain. What action should the nurse take first?

Determine the characteristics of the pain

A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the nurse give the client about this medication?

Drinking alcohol daily can cause drug-induced hepatitis

A client with hemiplegia is staring blankly at the wall and reports feeling like half a person. What is the most appropriate initial nursing action?

Offer to spend more time with the client.

The nurse recognizes that which are important components of a neurovascular assessment are:

Orientation, Respiratory rate, Pulse and skin temperature

The nurse discovers several palpable elevated masses on a client's arms. Which term most accurately describes the assessment findings?

Papules

When monitoring a client 24 to 48 hours after surgery, the nurse should assess for which problem associated with anesthetic agents?

Paralytic ileus

A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the nurse question?

Parenteral albumin (Albuminar)

What are the best ways for a nurse to be protected legally?

Provide care within the parameters of the state's nurse practice act, document consistently and objectively, Clearly document a client's non-adherence to the medical regimen

A client has received instructions to take 650 mg aspirin (ASA) every 6 hours as needed for arthritic pain. What should the nurse include in the client's medication teaching?

Take the aspirin with meals or a snack, Do not chew enteric-coated tablets, Report persistent abdominal pain

A nurse is teaching staff members about the legal terminology used in child abuse. What definition of battery should the nurse include in the teaching?

The application of force to another person without lawful justification.

The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this indicates the pulse is:

full

A client's serum potassium level has increased to 5.8 mEq/L. What action should the nurse implement first?

Take vital signs and notify the charge nurse or health care provider

A client has been diagnosed with type 1 Diabetes Mellitus. When providing instructions on sharps disposal, the nurse should instruct the client to place the syringes in:

A plastic liquid detergent bottle with a screw-top lid

The family of an older adult who is aphasic reports to the nurse manager that the primary nurse failed to obtain a signed consent before inserting an indwelling catheter to measure hourly output. What should the nurse manager consider before responding?

A separate signed informed consent for routine treatments is unnecessary

A client is scheduled to receive phenytoin (Dilantin) 100 mg orally at 6 PM but is having difficulty swallowing capsules. What method should the nurse use to help the client take the medication?

Administer 4 mL of phenytoin suspension containing 125 mg/5 mL

A nurse is taking care of a client who has severe back pain as a result of a work injury. What nursing considerations should be made when determining the client's plan of care?

Ask the client what is the client's acceptable level of pain & administer the pain medications regularly around the clock

A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client?

Blood lab results

When performing a postoperative assessment, which parameter would alert the nurse to a common side effect of epidural anesthesia?

Decreased blood pressure

A nurse reviews a medical record of a client with ascites. What does the nurse identify that may be causing the ascites?

Decreased liver function

According to Kübler-Ross, during which stage of grieving are individuals with serious health problems most likely to seek other medical opinions?

Denial

What should the nurse do initially when obtaining consent for surgery?

Determine whether the client's knowledge level is sufficient to give consent

What nursing actions best promote communication when obtaining a nursing history?

Establishing eye contact, paraphrasing the client's message, using broad, open-ended statements

A client diagnosed with tuberculosis is taking isoniazid (INH). To prevent a food and drug interaction, the nurse should advise the client to avoid:

Red wine

When meeting the unique preoperative teaching needs of an older adult, the nurse plans a teaching program based on the principle that learning:

Requires continued reinforcement

The nurse is caring for a client that is hyperventilating. The nurse recalls that the client is at risk for:

Respiratory alkalosis

A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes?

Respiratory and urinary

A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency?

Tachycardia & muscle weakness

A client comes to the clinic complaining of a productive cough with copious yellow sputum, fever, and chills for the past two days. The first thing the nurse should do when caring for this client is to:

Take the temperature

What should the nurse include in dietary teaching for a client with a colostomy?

The diet should be adjusted to include foods that result in manageable stools

The nurse is discussing discharge plans with a client who had a myocardial infarction. The client states, "I'm worried about going home." The nurse responds, "Tell me more about this." What interviewing technique did the nurse use?

Exploring

A client with arthritis increases the dose of ibuprofen (Motrin, Advil) to abate joint discomfort. After several weeks the client becomes increasingly weak. The client is admitted to the hospital and is diagnosed with severe anemia. What clinical indicators does the nurse expect to identify when performing an admission assessment?

Melena, Tachycardia

A nurse teaches a client about wearing thigh-high anti-embolism elastic stockings. What would be appropriate to include in the instructions?

"You will need to apply them in the morning before you lower your legs from the bed to the floor."

A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment?

Pain history including location, intensity and quality of pain;Pain pattern including precipitating and alleviating factors

What is the maximum length of time a nurse should allow an intravenous (IV) bag of solution to infuse?

24 Hours

The nurse is preparing discharge instructions for a client that acquired a nosocomial infection, Clostridium difficile. What should the nurse include in the instructions?

The infection causes diarrhea accompanied by flatus and abdominal discomfort

A hospitalized client experiences a fall after climbing over the bed's side rails. Upon reviewing the client's medical record, the nurse discovers that restraints had been prescribed but were not in place at the time of the fall. What information should the nurse include in the follow-up incident report?

A listing of facts related to the incident as witnessed by the nurse

A nurse is caring for an older adult who is taking acetaminophen (Tylenol) for the relief of chronic pain. Which substance is mostimportant for the nurse to determine if the client is taking because it intensifies the mostserious adverse effect of acetaminophen?

Alcohol

Which nursing activities are examples of primary prevention?

Assisting with immunization programs, facilitating a program about smoking cessation

A nurse is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure?

Clean the eyelid and eyelashes, apply clean gloves before beginning of procedure, Press on the nasolacrimal duct after instilling the solution

A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful?

Clear breath sounds

A client with rheumatoid arthritis does not want the prescribed cortisone and informs the nurse. Later, the nurse attempts to administer cortisone. When the client asks what the medication is, the nurse gives an evasive answer. The client takes the medication and later discovers that it was cortisone. The client states an intent to sue. What factors in this situation must be considered in a legal action?

Clients have a right to refuse treatment, nurses are required to answer clients truthfully, the health care provider should have been notified

When assessing a client's blood pressure, the nurse notes that the blood pressure reading in the right arm is 10 mm Hg higher than the blood pressure reading in the left arm. The nurse understands that this finding:

is a normal occurrence

A nurse reinforces teaching a client about Coumadin (warfarin) and concludes that the teaching is effective when the client states, "I must not drink:

Cranberry juice

A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client?

Evaluation

After abdominal surgery a client reports pain. What action should the nurse take first?

Determine the characteristics of the pain.

The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia?

Flushed face, increased pulse rate

A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions?

Frequent changes of position

What are the desired outcomes that the nurse expects when administering a nonsteroidal antiinflammatory drug (NSAID)?

Pain relief, antipyresis, reduced inflammation

What are the clinical indicators that a nurse expects when an intravenous (IV) line has infiltrated?

Pallor, edema, decreased flow rate

A nurse must establish and maintain an airway in a client who has experienced a near-drowning in the ocean. For which potential danger should the nurse assess the client?

Pulmonary edema

A nurse educator is presenting information about the nursing process to a class of nursing students. What definition of the nursing process should be included in the presentation?

Sequence of steps used to meet the client's needs

Which drug requires the nurse to monitor the client for signs of hyperkalemia?

Spironolactone (Aldactone)

A client with Addison's disease is receiving cortisone therapy. The nurse expects what clinical indicators if the client abruptly stops the medication?

Tachypnea, hypotension

A graduate nurse is preparing to apply to the State Board of Nursing for licensure to practice as a licensed practical nurse. What group primarily is protected under the regulations of the practice of nursing?

The public

The nurse recognizes that what is the reason the faucets on the sinks in a client's room are considered contaminated?

They are touched by dirty hands when turning the water on.

During history taking, a client reports experiencing black, tarry stools. The nurse recognizes that this may be an indication of

Upper gastrointestinal bleeding

A health care provider prescribes an antibiotic intravenous piggyback (IVPB) twice a day for a client with an infection. The health care provider prescribes peak and trough levels 48 and 72 hours after initiation of the therapy. The client asks the nurse why there is a need for so many blood tests. The nurse's best response is, "These tests will:

determine adequate dosage levels of the drug