Exam 1 N112
1) A client who had outpatient surgery is given an instruction sheet in preparation for discharge. When the nurse asks if the instructions are clear, the client says, "I'll read them later when I have my glasses; besides, you told me everything I need to know." Based on these statements, what would the nurse suspect? A) The client may be unable to read the instructions. B) The client already knows the information. C) The client does not want the written information. D) The client is ready to learn.
A
5) A community health nurse runs a clinic that provides health screening mainly to Mexican American and Filipino American clients. The nurse wants to have a class on smoking cessation for interested adults of this group. What action should the nurse take to adjust to their time orientation? A) Organize the instructions around short-term objectives. B) Mail letters ahead of time to make sure clients are informed about the upcoming class. C) Make posters and place them in areas of the community frequented by these groups. D) Make sure that the classes are held at specific times.
A
5) An older adult client is experiencing confusion, a temperature of 101.5°F, bruising to the arms and legs, and decreased urine output. The medical diagnosis is a urinary tract infection. Which is the most appropriate nursing diagnosis for this client? A) Risk for Injury B) Ineffective Breathing Pattern C) Activity Intolerance D) Impaired Memory
A
5) The urgent care clinic nurse is treating a client who is experiencing abdominal pain. The client states, "I think I ate tainted food last night." What should the nurse do after the client states that the food was tainted? A) Ask the client open-ended questions to further assess the situation. B) Tell the client the healthcare provider does not need to assess the client. C) Call an ambulance before assessing the client any further. D) Advise the client to take an antacid.
A
6) Which of the following total serum calcium levels would be considered normal in an adult client? A) 9.88 mg/dL B) 2.21 mg/dL C) 4.87 mg/dL D) 7.03 mg/dL
A
3) The nursing student is planning an educational program for a school project. The program is focusing on cancer detection education for a community group. What should the nursing student plan to include in order to address the various learning styles of the target group? A) A lecture using many examples for each learning need B) Multicolored brochures with bright colors C) A game board with client matching terms D) Audiovisuals, examples, group discussions, and activities
D
4) The nurse is collecting data about a client's current health status. Which statement would assist in gathering subjective data about the client? A) "Your eyelid is red and swollen." B) "Your skin appears to be dry and irritated." C) "I see that you have bruises on your legs." D) "Tell me why you have difficulty sleeping."
D
3) The nursing instructor is evaluating a concept map created by a student for a client's plan of care. Which characteristics on the map indicate that the student created the map appropriately? Select all that apply. A) Legend created identifying nursing process phases and client information categories B) Lines drawn between assessment data and associated nursing diagnoses C) Different colors used to represent the phases of the nursing process D) A column entitled "evaluation" located on the outer edge of the document E) A checklist located at the bottom of the document
A, B, C
6) A nurse is providing a series of educational workshops for caregivers of older clients interested in promoting the health and well-being of their clients. Which would be appropriate topics for this group? Select all that apply. A) Fall prevention B) Medication use and side effects C) Safe driving evaluations D) Advance directives E) Responsible sexual behavior
A, B, C, D
1) The nurse decides to use a standardized plan of care to address a client's health problems. Which criterion differentiates this plan of care from other types? Select all that apply. A) Is preprinted B) Has blank lines C) Has various shapes connected with lines D) Has checklists E) Includes different colors
A, B, D
10) The nurse is providing care to a client who is exhibiting clinical manifestations of a severe fluid and electrolyte imbalance. Based on this data, which of the following orders should the nurse anticipate from the healthcare provider? Select all that apply. A) Initiate intravenous therapy. B) Initiate hypodermoclysis. C) Administer antibiotics. D) Administer diuretics. E) Administer red blood cells
A, B, D
6) An experienced nurse practitioner is always conscious of the need to maintain a high level of competence within professional nursing practice. Which activities support this nurse's goal? Select all that apply. A) Reading professional journals B) Collaborating with peers C) Counseling clients D) Attending professional workshops and seminars E) Administering medications appropriately
A, B, D
4) A nurse educator on an oncology unit is teaching staff nurses about advance directives. Which elements will the nurse include in the teaching session? Select all that apply. A) The surrogate decision maker has the authority to consent to any medical treatment or diagnostic procedure. B) The surrogate decision maker has the authority to consent to only lifesaving medical treatments. C) The surrogate decision maker has the authority to authorize admission only to medical facilities and not long-term care facilities. D) The surrogate decision maker has the authority to have access to all medical records. E) The surrogate decision maker has the authority to refuse any medical treatment or diagnostic procedure
A, B, D, E
3) After discussing advance directives during a home visit, an older adult client decides to prepare documents for future care needs. Which actions by the nurse are appropriate in this situation? Select all that apply. A) Telling the client that changes to the advance directive can be made at any time B) Telling the client that it is not necessary to make decisions about healthcare needs in the future C) Giving a copy of the advance directives to the client's adult children D) Educating the client about the purpose and types of life-sustaining measures E) Having the client name an individual to be responsible for care decisions
A, C, D
12) The nurse is taking the time to reflect on a care situation in which a client sustained a cardiac arrest and died. On which areas should the nurse focus when performing this reflection? Select all that apply. A) Things that could have been done differently B) Gut reactions to the situation C) Things that were done well D) Resources that were used at the time E) Resources that were needed but not available
A, C, D, E
10) A nurse enters a client's room to evaluate the response to IV pain medication administered by request 20 minutes earlier. The nurse finds the client in the same position as when the medication was administered. The client states, "I do not want to move." The nurse asks the client to rate the current level of pain. Which aspects of the nursing process do these action represent? Select all that apply. A) Assessment B) Diagnosis C) Planning D) Implementation E) Evaluation
A, D, E
1) A nurse is preparing to discharge a client who experienced a myocardial infarction. The client will have to make many lifestyle changes, and the nurse is providing instruction on how to implement a heart-healthy lifestyle. Which is the best description of the client education the nurse is presenting to this client? A) Dependent function of nursing that needs a healthcare provider's order to implement B) Important independent nursing function C) Activity nurses begin to learn after training on the job D) Way to establish the client's dependence on the nurse
B
14) The nurse who uses clinical decision making to start CPR on a client is concerned about what other nursing concept? A) Cognition B) Perfusion C) Thermoregulation D) Acid-base balance
B
2) The nurse is caring for a client who is 3 days postoperative following an emergency appendectomy. The nurse is reviewing the client's lab values and notes that the client's calcium levels have increased since before the surgery. Which intervention should the nurse implement to decrease the client's possibility of developing hypercalcemia? A) Measure the client's vital signs every 8 hours. B) Assist the client in ambulating around the room at least three times daily. C) Irrigate the client's Foley catheter daily. D) Help the client turn, cough, and deep breathe every 2 hours.
B
21) ________ is a process whereby fluid and solutes move together across a membrane from an area of higher pressure to one of lower pressure. A) Osmosis B) Filtration C) Active transport D) Diffusion
B
4) A nurse is working in a neonatal intensive care unit (NICU). The nurse wants to teach a mother of a premature baby how to give her baby a bath. Which statement by the mother reflects a readiness to learn? A) "You'll give us written instructions before we go home, correct?" B) "When my baby is just a little bigger, I'll feel more comfortable giving him a bath." C) "I want to make sure my husband is here, in case I don't hear everything that's said." D) "I'm so afraid I'll hurt my baby with all these tubes and wires."
C
4) A nurse, who has been working in a small rural hospital for 4 years since obtaining a nursing license, participates on an interdisciplinary task force to improve client care. Which skill level is this nurse demonstrating according to Benner's stages of nursing expertise? A) Advanced beginner B) Competent C) Proficient D) Expert
C
4) The nurse is assigned two clients. One client needs postoperative teaching in preparation for discharge, and the other client with pneumonia has a PaCO2 of 85. Why does the nurse decide to see the client with pneumonia first? A) The nurse can delegate postoperative teaching to unlicensed assistive personnel (UAP). B) The client with pneumonia needs more care than the client needing postoperative teaching. C) The client with pneumonia may be experiencing respiratory distress. D) The room of the client with pneumonia is closer than that of the client needing postoperative teaching
C
13) The nurse reviewing lab results on one of her adult clients notices the client's serum sodium level is 150 mg/dL. Based on this data, which interventions should the nurse plan for this client? Select all that apply. A) Monitor heart rate and rhythm. B) Elevate the head of the bed. C) Instruct on a low-sodium diet. D) Administer diuretics as prescribed. E) Administer potassium supplement as prescribed.
C, D
13) A client diagnosed with heart failure is prescribed an oral fluid restriction of 1200 mL per day. How many ounces of fluid would the client be permitted during the day shift? A) 200 mL B) 300 mL C) 400 mL D) 600 mL
D
18) Which of the following electrolytes would be classified as a cation? A) Chloride B) Bicarbonate C) Phosphate D) Potassium
D
19) Which statement is true? A) A dehydrated client would be considered to be in a hypotonic state because the client would have a lower concentration of solutes in the body in relation to water. B) A dehydrated client would be considered to be in a hypertonic state because the client would have a lower concentration of solutes in the body in relation to water. C) A dehydrated client would be considered to be in a hypotonic state because the client would have a higher concentration of solutes in the body in relation to water. D) A dehydrated client would be considered to be in a hypertonic state because the client would have a higher concentration of solutes in the body in relation to water.
D
5) The novice nurse is writing his first nursing plan of care. He includes category headings for each phase of the nursing process, includes specific and detailed information related to interventions using complete sentences, considers the client's preferences in the chosen interventions, and incorporates preventive and restorative interventions. He then signs and dates the nursing plan of care. What did the nurse do wrong when creating the plan of care? A) He should not have used category headings for each phase of the nursing process. B) He should not have included preventive measures in the care plan until restorative goals were met. C) He should have included the physician's preferences for care rather than the client's preferences. D) He should have used approved abbreviations and key words rather than complete sentences
D
6) An older adult client with heart failure is experiencing activity intolerance due to dyspnea on exertion. Which nursing intervention is a priority for the client? A) Complete all nursing care at the end of the shift. B) Delegate care for the client to an aide. C) Complete all nursing care in the morning. D) Pace nursing care throughout the shift.
D
7) A client recovering from knee surgery is being prepared to ambulate for the first time. Prior to getting the client up, what should the nurse do? A) Ask the client about readiness to walk. B) Call for a wheelchair to start the process. C) Conduct a breathing assessment. D) Evaluate the client's level of pain.
D
8) A nurse is caring for a child who is hospitalized for an exacerbation of asthma. The nurse is preparing discharge teaching, as the client will be going home on nebulizer treatments and an inhaler. The client and her family members, who are recent immigrants to the United States, speak little English. In addition to enlisting an interpreter to help with the language barrier, what should be a priority for the nurse in developing a teaching plan? A) Provide written instructions before discharge. B) Make sure the parents can set up the treatments for their child. C) Make sure the child comes back for the follow-up appointment. D) Address any healing beliefs the family has.
D
9) The nurse is caring for a client who has been diagnosed with diabetes mellitus. The client must learn how to independently perform fingerstick blood sugar analysis as part of the plan of care. The client says, "I already know what you are attempting to teach because I looked everything up on the internet." Which is the best action by the nurse based on the client's statement? A) Document that the client understands teaching. B) Teach the client's support system how to perform the procedure. C) Give the client printed learning materials. D) Watch the client perform a return demonstration of the skill.
D
A nurse receives a shift report and is preparing to care for clients assigned on a medicalsurgical unit. Which client should the nurse plan to assess first? A) The client who needs assistance with activities of daily living B) The client who needs help ambulating to the bathroom C) The client with a pain rating of 3/10 D) The client experiencing shortness of breath
D
5) A nursing student has been assigned to present a teaching project to the class, using each of Bloom's taxonomy domains. The student has planned several activities to include when presenting the project to the class. Which activities are within the affective domain? Select all that apply. A) Class members must read a paragraph about a new clinical trial, summarize the information, and present it to the rest of the class. B) Class members must list the technical skills they have learned. C) Class members must demonstrate a favorite nursing skill for the class. D) Class members must reflect on how they felt the first time they provided direct client care. E) Class members must identify two attitudinal changes that have occurred in their lives since beginning their nursing education
D, E
7) The nurse educator is preparing to teach a group of nursing students how to navigate the internet to research healthcare information. Which does the educator plan to include during lecture? A) A directory of campus internet sites of interest B) How to search for and evaluate health information C) A directory of libraries D) Information technology instruction
B
7) The nurse is caring for a client diagnosed with heart failure who is admitted to the medicalsurgical unit with acute hypokalemia. Which drug on the client's medication administration record may have contributed to the client's current hypokalemic state? A) Demerol B) Cortisol C) Hydrochlorothiazide D) Skelaxin
B
7) The nurse is caring for a client with a new tracheostomy. After completing a teaching session on tracheostomy care, what should the nurse include in the documentation? A) The language used for teaching B) The need for additional teaching C) The client's questions after the teaching session D) The supplies required for teaching
B
7) ________ is a state of being in which individuals engage in behaviors that enhance their quality of life and maximize their personal potential. A) Health promotion B) Wellness C) Prevention D) Health restoration
B
8) An older adult client is admitted to the hospital after a fall. The client is intermittently confused. Based on age and current data, which of the following conditions is the client most at risk for developing? A) Kidney damage B) Dehydration C) Stroke D) Bleeding
B
11) A novice nurse is planning care for an older adult client with a wound infection and systemic blood infection. The nurse completes the plan of care and decides to complete which action to enhance the skill of critical thinking? A) Discuss the plan with the physician. B) Request that the client review the plan. C) Request a review of the plan with the nurse's preceptor. D) Place the plan on the client's chart.
C
12) The nurse identifies the diagnosis Risk for Impaired Skin Integrity as applicable for a client diagnosed with heart failure. Which assessment finding supports the use of this diagnosis for the client? A) Shortness of breath with ambulation B) Productive cough C) +3 pitting edema both feet D) Heart rate 104 and regular
C
15) The nurse is reviewing laboratory values for a female client suspected of having a fluid imbalance. Which laboratory value should indicate a diagnosis of dehydration to the nurse? A) Serum osmolality 230 mOsm/kg B) Hematocrit 30% C) Hematocrit 53% D) Serum potassium 3.8 mEq/L
C
15) What is the principal mineralocorticoid that assists in regulating the body's serum sodium balance? A) Antidiuretic hormone B) Parathyroid hormone C) Aldosterone D) Progesterone
C
16) The nurse is analyzing the intake and output record for a client being treated for dehydration. The client weighs 176 lb and had a 24-hour intake of 2000 mL and urine output of 1200 mL. Based on this data, which conclusion by the nurse is the most appropriate? A) Treatment needs to include a diuretic. B) Treatment has not been effective. C) Treatment is effective and should continue. D) Treatment has been effective and should end.
C
17) An increase in blood hydrostatic pressure would result in which fluid volume disturbance? A) Fluid volume excess, because the pressure would force fluid out through the lymphatic system and into the interstitial compartment. B) Fluid volume deficit, because the pressure would force fluid out of the interstitial compartment and into the lymphatic system. C) Fluid volume excess, because the pressure would force fluid out through the capillary walls and into the interstitial compartment. D) Fluid volume deficit, because the pressure would force fluid out of the interstitial compartment and into the capillaries.
C
4) The nurse is planning care for a client admitted to the unit with a diagnosis of dehydration. The client's lab values indicate a low level of serum sodium. Based on the assessment finding, the nurse determines that Risk for Electrolyte Imbalance is an appropriate nursing diagnosis. Which medical condition supports this nursing diagnosis? A) Isotonic dehydration B) Hydrostatic pressure C) Hypotonic dehydration D) Osmotic pressure
C
5) A home health nurse is providing care for a client diagnosed with heart failure. The client is taking furosemide (Lasix). The nurse reviews the client's most recent serum potassium, which was 3.4 mEq/L. Based on this data, which food should the nurse encourage the client to consume? A) Baked fish B) Iced tea C) Banana D) Peas
C
20) Which of the following lab values is indicative of hypokalemia? A) Serum potassium of 3.25 mEq/L B) Serum potassium of 5.45 mEq/L C) Serum sodium of 125 mEq/L D) Serum sodium of 155 mEq/L
A
3) A goal of care for a client with congestive heart failure (CHF) is for serum sodium levels to be within normal limits. Which information documented in the medical record would indicate that the client is not meeting this goal? A) The client is experiencing dependent edema. B) The client experiences joint pain. C) The client is constipated. D) The client is experiencing wheezing respirations.
A
3) Which theory of learning holds that knowledge acquisition is the ongoing assimilation and accommodation of new experiences and interpretations? A) Constructivist B) Behaviorist C) Social learning D) Cognitive
A
4) A pediatric nurse is assigned phone triage for the shift. The nurse takes a call from the mother of a 3-month-old infant. The mother tells the nurse that the child has been vomiting and experiencing diarrhea for several days. Based on this information, which response by the nurse is most appropriate? A) "You should bring the infant in to be seen by the doctor." B) "Give your baby at least 2 ounces of juice every 2 hours." C) "Give your baby 50 mL of glucose water every hour." D) "Measure your baby's urine output for 24 hours and call back tomorrow."
A
4) The nurse is caring for a client who has recently received a permanent colostomy. The client will be going home in several days and requires discharge teaching. What should the nurse do when organizing the teaching experience? A) Ask the client to tell the nurse what he knows about caring for the colostomy. B) Make sure the client's spouse is present before the teaching session begins. C) Start from the beginning and proceed through all steps required to perform colostomy care. D) Break the information into small sessions to enhance learning.
A
1) A novice nurse on a medical-surgical unit is released from the orientation phase of training. The nurse is able to care for a four- to five-client assignment independently and is assigned a coach on the unit who will help with problem solving if needed. According to Benner's stages of nursing expertise, this nurse would belong in which stage? A) Stage II B) Stage V C) Stage III D) Stage IV
A
1) During a health history, a client becomes upset because the nurse is asking many questions. Which response by the nurse is the most appropriate in this situation? A) "I use the answers to determine your current health needs." B) "I am sorry the questions disturb you." C) "I will skip the questions that bother you." D) "I cannot help you if you do not answer me."
A
1) The nurse on a medical-surgical unit completes the shift assessment for a client diagnosed with a multisystem fluid volume deficit. In the assessment, the nurse documents that the client is experiencing tachycardia, decreased urine output, and pale, cool skin. Based on this information, which should the nurse anticipate as the cause of the client's current symptoms? A) Natural compensatory mechanisms B) Cardiac failure C) Pharmacological effects of a diuretic D) Rapidly infused intravenous fluids
A
10) A client asks the student nurse to explain the pathophysiology of diabetes. The student nurse does not know the answer to this question. What should the student respond to the client? A) "I do not know, but I will find out." B) "You'll have to ask the doctor that question." C) "Why do you need to know that?" D) "I do not know."
A
14) The nurse is instructing a client diagnosed with heart failure about a prescribed sodium restricted diet. Which client statement indicates that additional teaching is required? A) "I can use as much salt substitute as I want." B) "I have to read the labels on foods to find out the sodium content." C) "I have to limit the intake of food with baking soda or baking powder." D) "I can use spices and lemon juice to add flavor to food when cooking."
A
16) Which of the following statements is correct with regard to hypercalcemia? A) Hypercalcemia is often a result of hyperparathyroidism, because the increased levels of parathyroid hormone associated with this condition cause an increase in the amount of calcium in the blood. B) Hypercalcemia is often a result of hyperparathyroidism, because the decreased levels of parathyroid hormone associated with this condition cause an increase in the amount of calcium in the blood. C) Hypercalcemia is often a result of hypoparathyroidism, because the increased levels of parathyroid hormone associated with this condition cause an increase in the amount of calcium in the blood. D) Hypercalcemia is often a result of hypoparathyroidism, because the decreased levels of parathyroid hormone associated with this condition cause an increase in the amount of calcium in the blood
A
2) A home health nurse is working with a client who has chronic obstructive pulmonary disease. Which nursing diagnosis will take the highest priority for implementing client education? A) Impaired Gas Exchange B) Ineffective Breathing Pattern C) Anxiety D) Activity Intolerance
A
2) The nurse is caring for an adult client who has been diagnosed with high cholesterol. Which is important for the nurse to consider when teaching this adult client? A) Adults are more oriented to learning when the material is useful immediately. B) Adults are more likely to adhere to a regimen than are children. C) Adults usually can find information on their own. D) Adults do not need to be evaluated for understanding as children do.
A
6) The nurse working on a medical unit is admitting a client diagnosed with heart failure. During the admission process, the client states, "I do not want to be put on a ventilator because I had to watch my mother die on a ventilator. I want information on making out a living will." When planning care for this client, which intervention is the most appropriate? A) Educate the client on the process and purpose of a living will and arrange for one to be created should the client choose to do so. B) Encourage the client to allow for mechanical ventilation. C) Educate the client on the purpose of mechanical ventilation. D) Refer the client to a therapist to deal with the death of her mother.
A
7) A client is admitted to the emergency department for vomiting and diarrhea that has lasted 4 days. The client's current weight is 154 pounds. The healthcare provider has diagnosed the client with a viral infection. The nurse has been monitoring intravenous fluids and urine output. Which urinary output would indicate that efforts to rehydrate this client have been successful? A) 40 mL per hour B) 20 mL per hour C) 25 mL per hour D) 30 mL per hour
A
7) The home health nurse is visiting a client who is 2 weeks postoperative from a coronary artery bypass surgery. The client has lost 10 pounds, is continuing to experience pain, and is not eating. What should be the nurse's next action? A) Examine the current interventions for pain relief. B) Refer the client to social services. C) Contact Meals on Wheels so that the client will eat. D) Revise the goals in the current plan of care.
A
8) The nurse is caring for a client with a potassium level of 5.9 mEq/L. The healthcare provider prescribes both glucose and insulin for the client. The client's spouse asks, "Why is insulin needed?" Which response by the nurse is the most appropriate? A) "The insulin will cause extra potassium to move into his cells, which will lower the potassium level in the blood." B) "Insulin is safer than other medications that can lower potassium levels." C) "The insulin lowers his blood sugar levels and causes the extra potassium to be excreted." D) "The insulin will help his kidneys excrete the extra potassium."
A
9) The nurse has a 7-year-old client recovering from partial-thickness burns to the arms and hands. This client has shown sensitivity to loud noises and bright lights, and at times if she is overstimulated she won't speak to or look at anyone but her parents until she calms down. The nurse considers the best teaching environment for this client to be the A) client's room. B) pediatric ward waiting area. C) hospital cafeteria. D) pediatric ward play area
A
1) An older adult client is brought to the emergency department. The client has been experiencing fever, nausea, and vomiting for the past 2 days. The client denies thirst. Urine dipstick indicates a decreased urine specific gravity. Based on this data, which diagnosis should the nurse most anticipate for this client? A) Congestive heart failure B) Dehydration C) Fluid overload D) Normal changes of aging
B
11) A construction worker admitted to the unit with a chest injury and broken ribs from a fall from a ladder has nursing diagnoses of "Disturbed Sleep Pattern," "Ineffective Breathing Pattern," and "Risk for Infection." The client states, "I've never been sick a day in my life and am really worried about how I can support my family while I'm out of work." When evaluating the client's plan of care during the shift, the nurse adds the nursing diagnosis "Anxiety" to the plan of care. Which diagnosis would be the priority for nursing interventions? A) Risk for Infection B) Ineffective Breathing Pattern C) Disturbed Sleep Pattern D) Anxiety
B
11) The nurse is preparing to administer 20 mEq of potassium chloride to a client who has been vomiting. Which information about the purpose of this medication should the nurse explain to the client? A) It is vital in regulating muscle contraction and relaxation. B) It is needed to maintain skeletal, cardiac, and neuromuscular activity. C) It controls and regulates water balance in the body. D) It is used to synthesize protein and DNA within the body's cells.
B
14) During an assessment, the nurse becomes concerned that an older adult client is at risk for dehydration. Which of the following assessment findings would cause the nurse to come to this conclusion? A) The client has poor skin turgor. B) The client reports ingesting two glasses of water each day. C) The client's blood pressure is 140/98 mmHg. D) The client's body mass index is 20.5.
B
17) During an assessment, the nurse learns that a client who is seeking emergency treatment for a headache and nausea works in a mill without air conditioning. The current air temperature outside is 88 degrees, and the client reports drinking water several times throughout the day because of heavy sweating. Based on this data, which instruction is most appropriate for the nurse to give the client? A) "Eat something sweet when drinking water." B) "Eat something salty when drinking water." C) "Double the amount of water you are drinking." D) "Drink juices and carbonated sodas instead of water."
B
2) The nurse receives a shift report on a pediatric medical-surgical unit. The nurse has been assigned four clients for the shift. Which client should the nurse plan to assess first based on an increased risk for dehydration? A) A 4-year-old child with a broken leg B) A 15-month-old child with tachypnea C) A 16-year-old child with migraine headaches D) A 10-year-old child with cellulitis of the left leg
B
3) A nurse educator is talking to a group of staff nurses about the importance of continued competence in nursing practice. One of the staff nurses asks about activities that can help professional nurses maintain competence. Which action should the nurse educator recommend? A) Working overtime whenever hours are available B) Designing a poster presentation on current research on care for the dying client C) Volunteering to take blood pressures at a health and wellness fair D) Organizing a seminar to educate new nurses about hospital policies
B
5) The nurse on the medical unit is admitting a client. When the nurse asks the client about advance directives, the client states, "I have a living will." Which is the purpose of a living will? A) Provides specific instructions about type of medications the client requires to sustain life B) Provides specific instructions about what medical treatment the client does not want in the event they can no longer make decisions for themselves C) Provides specific instructions about who will make healthcare decisions if the client cannot D) Provides specific instructions about how decisions are to be made if the client is unable to make the decisions
B
6) A client with aspiration pneumonia is diaphoretic, pale, and taking gasping breaths. Which is the priority nursing action? A) Notify the healthcare provider. B) Complete a thorough cardiopulmonary assessment. C) Administer 10 L of oxygen per face mask. D) Reposition the client to help with breathing.
B
6) Which of the following terms refers to severe, generalized edema, which may occur as a result of fluid volume excess? A) Ascites B) Anasarca C) Hypervolemia D) Orthopnea
B
8) The nurse provides medication teaching for a client who will be going home on new medications. Which statement by the client best illustrates compliance with the medication plan? A) "I think you should have waited until I was ready to go home. Maybe I'd remember better." B) "I'm glad to know about my new medications. It makes taking them all a lot easier." C) "If I take my medications as prescribed, I'll feel better." D) "I already knew most of what you told me."
B
9) The nurse is caring for an older adult client who is receiving intravenous fluids at 150 mL/hr. Upon assessment, the nurse notes crackles, shortness of breath, and jugular vein distention. Based on this data, which complication of IV fluid therapy does the nurse anticipate? A) Speed shock B) Fluid volume excess C) Pulmonary embolism D) An allergic reaction
B
9) Which statements accurately reflect the distinction between nursing diagnoses and medical diagnoses? Select all that apply. A) A nursing diagnosis is determined following an assessment and analysis of data gathered only by registered nurses; a medical diagnosis is determined following an assessment and analysis of data gathered only by physicians. B) A nursing diagnosis changes as the client's responses to an illness or health situation change; a medical diagnosis remains the same as long as the disease process persists. C) A nursing diagnosis describes a client's physical, sociocultural, psychological, and spiritual responses to an illness or health condition; a medical diagnosis refers to disease processes. D) A nursing diagnosis considers the etiology of the health problem to give direction to required nursing care; a medical diagnosis does not consider the etiology of the health problem to give direction to medical care. E) A nursing diagnosis requires the nurses to consider standards and norms as well as cues from clients in discerning an appropriate nursing diagnostic label; a medical diagnosis uses standards and norms only.
B, C
10) The school nurse is preparing a class session for high school students on ways to maintain fluid balance during the summer months. Which interventions should the nurse recommend to decrease the risk of fluid imbalance? Select all that apply. A) Drink diet soda. B) Drink more fluids during hot weather. C) Drink flat caffeine-free cola or ginger ale if vomiting. D) Reduce the intake of coffee and tea. E) Exercise between the hours of 10 a.m. and 2 p.m.
B, C, D
12) The nurse is concerned that a client diagnosed with a fluid imbalance is at risk for an alteration in perfusion. Which assessment data should indicate to the nurse that the client is not currently experiencing an alteration in perfusion? Select all that apply. A) Skin turgor 20 seconds B) Peripheral pulses present and full C) Capillary refill of nail beds 3 seconds D) Oriented to person, place, and time E) Bowel sounds sluggish in all four quadrants
B, C, D
4) The nurse is selected to participate on a committee to write clinical pathways for a specific set of medical diagnoses. Which are advantages of using this approach when providing client care? Select all that apply. A) Link nursing diagnoses with specific assessment data B) Sequence the care that is to be given on a particular day C) Identify interventions, time frames, and expected outcomes D) List medical treatments to be performed by other providers E) Provide specific columns for diagnosis, interventions, and evaluation
B, C, D
2) The nurse is creating a four-column plan of care for a client. For which areas should the nurse prepare to document when creating this care plan? Select all that apply. A) Medications B) Nursing diagnosis C) Goals D) Interventions E) Evaluation
B, C, D, E
1) A client with terminal cancer has signed an advance directive indicating that no parenteral nutrition or hydration will be implemented. For several days the client has refused food and fluids, pushing the caregiver's hands away when attempts are made to feed the client or offer any kind of fluid. The family is considering placing a gastrostomy tube because they feel the client is "starving to death." Which actions by the nurse are appropriate? Select all that apply. A) Take the case to the hospital's ethics committee. B) Honor the client's refusal of parenteral nutrition and hydration. C) Talk to the healthcare provider so the family's wishes can be acted upon. D) Help the family come to terms with the situation. E) Honor the family's wishes and have them sign a consent form
B, D
5) A school nurse in a large urban high school regularly delivers presentations on nutrition, smoking cessation, and prevention of sexually transmitted infections (STIs). What area(s) of nursing competence is this nurse demonstrating? Select all that apply. A) Health restoration B) Health and wellness promotion C) Caring for the dying D) Illness prevention E) Care cost savings
B, D
8) A client who has just been diagnosed with type 2 diabetes mellitus is being instructed by the nurse regarding diet and exercise. Which client statements indicate that further teaching is required? Select all that apply. A) "I should talk to the doctor about an exercise program." B) "I don't need to watch my diet as long as I take my insulin." C) "I need to limit the amount of fat in my diet." D) "I should eat a candy bar when my energy is low." E) "I will test my blood sugar before meals and at bedtime."
B, D
13) A client begins to vomit blood. The nurse immediately measures the blood pressure and prepares to insert a nasogastric tube while directing others to notify the healthcare provider and prepare to perform iced saline lavage. Which features of the Tanner Clinical Judgment Model did this nurse demonstrate? Select all that apply. A) Presencing B) Noticing C) Reflecting D) Interpreting E) Responding
B, D, E
5) The nurse is caring for a client who is receiving intravenous fluids postoperatively following cardiac surgery. The nurse is aware that this client is at risk for fluid volume excess. The family asks why the client is at risk for this condition. Which response by the nurse is the most appropriate? A) "Fluid volume excess commonly occurs due to new onset liver failure caused by the surgery." B) "Fluid volume excess is frequently caused by the administration of intravenous fluids." C) "Fluid volume excess is common due to increased levels of antidiuretic hormone in response to the stress of surgery." D) "Fluid volume excess is frequently caused by inactivity."
C
6) A nurse has recently joined an orthopedic unit in the United States that specializes in perioperative care of clients undergoing knee or hip replacement. Which nursing plan of care is this nurse likely to use most often? A) Column plan B) Concept map C) Standardized plan D) Clinical pathway
C
6) A nurse is caring for a group of clients who are recovering in a rehabilitation hospital following total hip replacements. Which client is exhibiting the highest motivation to learn? A) A client who has been there the longest and is a great "coach" for newcomers B) A client who has been struggling with following nursing directives regarding discharge goals C) A client who is excited to learn ambulation techniques D) The client who has just moved in and is already eager for discharge
C
8) Providing wound care, referring clients to post-trauma psychological counseling, and assisting clients with physical and occupational therapy are all activities associated with which area of nursing competence? A) Health promotion B) Illness prevention C) Health restoration D) Holistic care and support
C
8) The nurse is caring for an older adult client with decreased energy who needs to get up to prevent the development of pressure ulcers. The client is unable to ambulate and wants to be alone. What should the nurse do? A) Notify the healthcare provider of the client's noncompliance. B) Leave the client alone until ready to get out of bed. C) Gain knowledge about the client from family to gain compliance. D) Proceed to get help to get the client out of bed.
C
9) A client in the emergency department is being admitted with a diagnosis of fluid volume deficit. When preparing to assess this client, on which body system should the nurse focus to determine the cause of the imbalance? A) Cardiovascular B) Genitourinary C) Gastrointestinal D) Musculoskeletal
C
9) The nurse is caring for an older school-age client who is sleeping when the menu choices for dinner are brought to the room. Which intervention should the nurse use to meet the dietary needs of this client? A) Wake the child to choose a meal for dinner. B) Order chicken nuggets because most children like this meal. C) Ask the dietary worker to come back later. D) Ask the parents to bring dinner from home for the client.
C
2) A client who sustained a traumatic brain injury several weeks ago is in a chronic vegetative state and is no longer competent to make healthcare decisions. Who should the nurse expect to make care decisions for this client? A) The physician B) The client's spouse C) Social services D) The agent named in the durable power of attorney
D
2) A client with congestive heart failure (CHF) is having difficulty breathing. Before leaving the room, the nurse ensures the client has an overbed table to lean on when awake if needed to ease breathing. Which technique did the nurse use to make this decision? A) Delegating a task B) Priority setting C) Conflict resolution D) Critical thinking
D
2) One of the roles of the community health nurse is to educate individuals about health promotion and wellness. Which activity would the nurse dismiss as irrelevant to health promotion and wellness? A) Holding classes for teenagers regarding prevention of sexually transmitted infections B) Teaching a class about smoking cessation C) Initiating infant care classes for new parents D) Implementing an exercise class for clients who have had a heart attack
D
2) The nurse is conducting a class for a group of expectant mothers regarding basic infant care techniques. What goal will allow the nurse to best evaluate the mothers' learning? A) The mothers will be able to set goals for the next class session. B) The mothers will be able to pass a written test on how to bathe a newborn infant. C) The mothers will be able to review the major points of the class. D) The mothers will be able to provide a return demonstration of a bath on a newborn doll.
D
3) A postoperative client prescribed pain medication every 4 to 6 hours is requesting medication every 6 hours. At 4 hours the client's pain level is 8 on a rating scale of 1 to 10. The nurse decides to give the pain medication now. What does this nurse's action exemplify? A) Meeting a client goal B) Time management skills C) Prioritizing the client's care D) Responding to a change in the client's condition
D
3) The nurse is reviewing the lab values for a client being cared for on the unit. The client's phosphorus level is currently 2.0 mg/dL. Based on this data, which nursing intervention is most appropriate for the nurse to implement? A) Enforce contact precautions. B) Encourage consumption of a high-calorie carbohydrate diet. C) Strain all urine. D) Encourage consumption of milk and yogurt.
D
3) The nurse is teaching a group of children and their parents about the prevention of heat-related illness during exercise. Which statement by a parent indicates an appropriate understanding of the preventive techniques taught during the session? A) "It is important for my child to wear dark clothing while exercising in the heat." B) "Water is the drink of choice to replenish fluids that are lost during exercise." C) "My child only needs to hydrate at the end of an exercise session." D) "I will have my child stop every 15 to 20 minutes during physical activity to drink fluids."
D
