exam 1 review

A client in traction reports feeling uncomfortable from being in the same position. Which nursing intervention is correct in this situation? 1: repositioning the client 2:offering basic hygiene measures 3:assisting the client with the meal 4:providing health teaching to the client

1

When learning about the rules of leaders, which action of the nurse indicates effective implementation of the rules? select all 1: communicating in a simple language with followers 2:giving an opportunity to the followers to express their views 3:instructing followers to decide the actions to be performed 4:avoiding communicating clear boundaries with followers 5:ensuring proper eye contact while communicating with followers

1,2,5

Which of the following patients are at risk for tachypnea? (rapid, shallow breathing) select all that apply 1:patient just admitted with four rib fractures 2:women who is 9 months pregnant 3:a patient admitted with hypothermia 4:postoperative patient waking from general anesthesia 5:three pack per day smoker with pneumonia

1,2,5

A client with a history of cardiac dysrythmias is admitted to the hospital due to a fluid volume deficit caused by a pulmonary infection. The RN assess the recorded vital signs. Which vital sign assessment requires reassessment? 1: Respiratory rate of 14B/M 2: Blood pressure: 120/80 3: O2 saturation of 95% 4:temporal temp of 99.3 5: radial pulse rate of 72 and irregular

1,2,3

Which example would be a normal blood pressure of a 12 year old client 1: 95/65 2:105/65 3:110/65 4:119/75

3

Which respiratory rate would the nurse expect for a 2 year old? 1:20 b/m 2:30 b/m 3:40 b/m 4:50 b/m

2

Which feedback given by the RN to the delegatee is constructive? select all 1: well done, nice job 2: I expected you to do better 3: you can do better when you concentrate 4: you performed that procedure safely and professionally 5: let me demonstrate a more effective way to perform the task

4,5

the nurse is caring for an older adult in a long term care setting. The nurse reviews the medical record to find that the patient has progressive loss of total bone mass. The patients history and tendency to take smaller steps with feet kept closer together will most likely result in which of the following? 1:increase the patients risk for falls and injuries 2:result in less stress on the patients joints 3:decrease the amount of work required for patient movement 4:allow for mobility in spite of the aging effects on the patients joints

1

According to maslows hierarchy of needs, in which order would the nurse prioritize actions 1: encouraging the client to talk about fears and feelings 2:praising the client for administering insulin accurately 3:providing a warm bath to the client to promote a good nights sleep 4:assisting the client in getting out of bed to join family members for meals.

3,1,4,2

The nurse applying effective communication skills throughout the nursing process should: (Place the following interventions in the correct order.) 1. Validate health care needs through verbal discussion with the patient. 2. Compare actual and expected patient care outcomes with the patient. 3. Provide support through therapeutic communication techniques. 4. Complete a nursing history using verbal communication techniques.

4,1,3,2

After presenting info about fall risk assessments to nursing staff, which participants statement needs review for corrective action? 1: "we will assess every admission to the unit" 2: "we will implement a valid falls risk assessment tool" 3: "we will apply yellow wrist bands to high risks clients" 4: "we will use the admission fall assessment for the entire stay"

4: fall risk assessment should be updated routinely through discharge, because fall risk may change throughout the hospital stay

The nurse prepares to assess a clients heart during a routine health checkup. In which position would the nurse place the client to assess murmurs of the heart?

lateral recumbent position (on side)

The nurse is assisting a client to transfer from the bed to a chair. Which would the nurse do to widen the base support during transfer? 1: spread the feet away from eachother 2:move the client on the count of three 3:tighten the core muscles 4:stand close to the client when assisting with the move

1

The nurse spends time with a patient and family reviewing a dressing change procedure for the patients wound. The patients spouse demonstrates how to change the dressing. The nurse is acting as which nursing role? 1:educator 2:advocate 3:caregiver 4:communicator

1

Which condition would the nurse associate with a clients regular and slow RR 1: apnea 2:bradypnea 3:tachypnea 4:hyperpnea

2

Which instructions would the nurse give to an older adult with decreased perception of touch? select all that apply 1:use a cane for support when walking 2:hold on to handrails while ambulating 3:look where you feet are place while walking 4:wear shoes that give good support while walking 5:if you are unable to change you position frequently, request assistance

2,3,4,5

Which of the following motivates a patient to participate in an exercise program? select all that apply 1:providing a patient with a pamphlet on exercise 2:providing information to the patient when he or she is ready to change behavior 3:explaining the importance of exercise 4:Having a structured daily plan that incorporates physical activity 5:Having support from significant other to engage in exercise

2,4,5

Which extrinsic factor is responsible for falls in older adults? select all that apply. 1:impaired vision 2:cognitive impairment 3:environmental hazards 4:inappropriate footwear 5:improper use of assistive devices

3,4,5

Which instruction provides a client the best description of how to use prescribed, stationary (nonrolling) walker? 1: place the walkers back leg tips about an arms length ahead of the feet, shift body weight to the walker, and step forward 2:move the walker about an arms length ahead while stepping forward and transferring body weight to all walker leg tips 3: put the walkers front leg tips about an arms length ahead of the feet, shift the body weight to the walker, and step forward 4: position the walkers front leg tips onto the floor about an arms length ahead of the feet and step forward until all tips touch the floor

3:all walkers leg tips should be touching the floor when stepping forward.

Which response will the nurse provide when a family member asks why a client who is intubated and receiving mechanical ventilation has restraints in place? 1: the restraints will be removed once the client is extubated 2:we are required to restrain all clients with breathing tubes 3:restraints are a last resort to precent accidental extubation 4:it is routine procedure for us to restrain all intubated clients

3:restraints are the last resort to protect the airway and are only used as long as necessary

Two nurses are planning to help a client with one sided weakness move up in bed. Which principle of body mechanics would the nurse observe? 1: instruct the client to position one arm on each shoulder of the nurses 2: direct the client to extend the legs and remain still during the procedure 3:have both nurses shift their weight from the front leg to the back leg as they move the client up in bed 4:position the nurses on either side of the bed with their feet apart, gather the turn sheet close to the client, turn toward the head of bed and the move the client

4

Which activity performed by a nurse is related to maintaining competency in nursing practice? 1:Asking another nurse about how to change the settings on a medication pump 2:regularly attending unit staff meetings 3:participating as a member of the professional nursing council 4:attending a review course in preparation for a certification examination

4

Which clinical finding demonstrates to the nurse that the client can use a standard walker? 1:weak upper arm strength and impaired stamina 2:weight bearing as tolerated and unilateral paralysis 3:partial weight bearing on the affected extremity and kyphosis 4:strong upper arm strength and non weight bearing on the affected extremity

4

Which point requires correction regarding the use of restraints? 1:less restrictive interventions must have been unsuccessful before applying restraints 2:all other alternatives must have been tried and exhausted before applying restraints 3:restraints may be applied to ensure the physical safety of the resident or other residents 4:a written order for restraints is not required

4

Which type of fever does a client have when experiencing fever spikes combined with a normal body temp occurring at least once a day?? 1: sustained 2:relapsing 3:remittent 4:intermittent

4:sustained fever is a constant body temp greater than 100.04 relapsing fever is an occurrence of periods of febrile episodes with acceptable temp values remittent fever, the body temp increases and decreases without returning to normal body temp levels

The nurse is reviewing the procedure for intervention if a fire occurs. Which intervention would the nurse include in the procedure if a fire occurs that relate to the acronym RACE? select all that apply 1: activate the alarm 2:alert the local fire department 3:remove all clients from the area 4:evaluate all interventions provided 5:release the pin in the fire extinguisher 6:confine the fire by closing doors and windows

1,3,6: RACE: Remove all clients, Activate the alarm, Confine the fire by closing doors and windows, and extinguish the fire

The nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. Which step would the nurse do next after placing the nurse's arms under the client's axillae? 1:bending and then straightening their knees 2:bending at the waist and then straightening the back 3:placing one foot in front of the other and then leaning back 4:placing pressure against the clients axillae and the raising their arms

1:leg bones and muscles are used for weight bearing and are the strongest in the body. Using the knees for leverage while lifting the client shifts the stress of the transfer to the caregivers legs. Your back is protected from injury when using strong muscle and legs

Which step of the problem solving process would be most important for the nurse to consider when addressing a recent increase in client falls on the unit? 1: collecting recent data concerning the falls to clearly identify the problem 2:analyzing data collected to identify solutions to address issues contributing to falls 3:identifying risks and consequences of possible solutions to decrease falls on the unit 4:considering how ones own beliefs concerning causes of the recent increase may affect solutions

1:problem must first be identified to problem solve

A patient is experiencing some problems with joint stability in the right leg. The doctor has prescribed crutches for the patient to use while being allowed to bear weight only on the left leg. Which of the following gaits should the patient be taught to use? 1:four point 2:three point 3:two point 4:swing through

2

Which condition would the nurse associate with a clients regular and slow respiratory rate? 1:apnea 2:bradypnea 3:tachypnea 4:hyperpnea

2

Wrist restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. Which nursing intervention is correct regarding restraints? 1: have the prescription renewed every 48 hours 2:assess the clients condition per hospital protocol 3:provide range of motion exercises to the clients wrist every shift 4:document output from the nasogastric tube and catheter every 2 hours

2

Nurses must communicate effectively with the health care team for which of the following reasons? (Select all that apply.) 1. Improve the nurse's status with the health team members 2. Reduce the risk of errors to the patient 3. Provide optimum level of patient care 4. Improve patient outcomes 5. Prevent issues that need to be reported to outside agencies

2,3

The nurse uses silence as a therapeutic communication technique. What is the purpose of the nurse's silence? (Select all that apply.) 1. Prevent the nurse from saying the wrong thing 2. Prompt the patient to talk when he or she is ready 3. Allow the patient time to think and gain insight 4. Allow time for the patient to drift off to sleep 5. Determine if the patient would prefer to talk with another staff member

2,3

The nurse therapeutically responds to an adult patient who is anxious by: (Select all that apply.) 1. Matching the rate of speech to be the same as that of the patient 2. Providing good eye contact 3. Demonstrating a calm presence 4. Spending time attentively with the patient 5. Assuring the patient that all will be well

2,3,4

Which activities would the nurse perform to meet the clients safety and security needs based on maslows hierarchy of needs? select all that apply 1:providing a cold bath to reduce the clients body temp 2:positioning the bed in a low position and keep the side rails up 3:monitoring vital signs, such as blood pressure to decrease the risk of falls 4:observing a client who has suicidal tendencies to prevent adverse incidents 5:collaborating with the family members to provide emotional support for the client post-surgery

2,3,4

Which physiological factor helps maintain BP in the client with hypovolemia (blood loss)? select all that apply 1:arteriolar dialtion 2:release of aldosterone 3:activation of angiotensin 11 4:sympathetic nervous system activation 5:stimulation of the vagus nerve

2,3,4

After a home assessment of an older adults fall risk, which intervention would the nurse suggest? select all that apply 1:dimming lighting to avoid squinting 2:secure rugs to prevent movement 3:remove excessive pieces of furniture 4:wear corrective lenses for distance vision 5:perform exercises to strength lower extremities

2,3,4,5

Which intervention by the nurse would be beneficial to promote a healthy lifestyle in an older adult client who lives alone at home and refrains from physical activity for fear of falling when walking? 1:instruct the client to apply bedside rails. select all 2:encourage the client to wear nonskid shoes 3:suggest the the client use an assistive device 4:ask the client to install handrails in the bathroom 5:help the client rearrange furniture in the house

2,3,5

Which education would the nurse provide the parent of a preschooler about safety? select all that apply 1:have your child sleep on their back or side 2:teach your child physical safety rules 3:allow your child to be friendly to strangers 4:remove doors from unused refrigerators and freezers 5:avoid teaching your child to cross roads and walk in parking lots

2,4

A nurse works with a patient using therapeutic communication and the phases of the therapeutic relationship. Place the nurses statements in order according to these phases. 1:The nurse states, "lets work on learning injection techniques" 2:the nurse is mindful of his/her own biases and knowledge in working with the patient with B12 deficiency 3:The nurse summarizes progress made during the nursing relationship 4:after providing introduction, the nurse defines the scope and purpose of the nurse-patient relationship

2,4,1,3

In which order would the nurse follow steps of risk management to identify potential hazards and to eliminate them before harm occurs? 1:acting to reduce the risks 2:identifying possible risks 3:evaluating the steps taken 4:analyzing the possible risks

2,4,1,3

During admission of an obese patient with heart failure the assistive personnel reports that the BP is 140/76 on the left arm and 128/72 on the right arm. What actions do you take on the basis of this information? select all that apply 1: notify the health care provider 2:repeat the measurements on both arms using a stethoscope 3:ask the patient if she has taken her BP medications recently 4:obtain BP measurements on lower extremities 5:verify that the correct cuff size was used during the measurements 6:review the patients baseline vital signs 7:compare right and left radial pulses for strength

2,6

The nurse has provided teaching to a client who has impaired balance and uses a walker. Which observation of the client would indicate to the nurse that further teaching is required? 1: slides towards the edge of the seat before standing 2: holds both handles of the walker while rising to stand 3:moves forward into the walker after transferring from sitting to standing 4: stands in place holding on to the walker for atleast 30 seconds before walking

2-because of the force applied to the walker and angle, the walker can become unstable and tip over

the nurse is managing care for a client who has had a total hip arthroplasty. Which action by the unlicensed assistive personnel will require the nurse to intervene? 1:the clients heels are kept off the bed 2:the UAP elevates the clients affected leg on a pillow 3:the UAP uses a pillow to keep the clients legs abducted 4:the client uses a walker when ambulating with the UAP

2-using a pillow to elevate the affected leg would cause flexion of the hip, which is to be avoided

A nurse is caring for a patient with end stage lung disease. The patient wants to go home on oxygen and be comfortable. The family wants the patient to have a new surgical procedure. The nurse explains the risk and benefits of the surgery to the family and discusses the patients wishes with them. The nurse is acting as the patients what? 1:educator 2:advocate 3:caregiver 4:communicator

2: Advocate nurses protect the patients human rights

Which action should the nurse manager take when it becomes apparent that communication between the nurse and the client is consistently superficial? 1: assess the clients ability to understand the nurse 2:evaluate how well the nurse uses active listening 3:reinforce the client the importance of sharing 4:review the nurses use of questioning techniques

2: a lack of effective listening on the part of the nurse commonly results in superficial, ineffective communication

The nurse provides crutch walking instructions to a client who has a left leg cast. Where would the nurse teach the client to place their weight? 1:in the axillae 2:on the hands 3:on the right side 4:on the side that client prefers

2: body weight should be placed on the hands

The nurse palpated the peripheral pulse of four different clients. Which client has an unacceptable heart rate? 1: 11 months: 156 b/m 2: 4 year: 105 b/m 3: 2 year 148 b/m 4: 14 year 87 b/m

2: heart rate decreases as you get older

Which instruction by the nurse is correct for a patient with a fractured leg? 1:double the intake of vitamin C 2:remove loose rugs from the environment 3:avoid taking showers until the cast is removed 4:increase weight bearing the injured leg gradually

2:loose rugs can interfere with crutch walking and cause a fall

During a falls risk assessment, which action would the nurse take after learning the client experienced a recent fall? 1:apply restraint to prevent ambulating without assistance 2:discontinue all medications to remove the risk of polypharmacy 3:assess the circumstances of the fall, including feeling and setting 4:require family members to remain at the bedside to watch over client

3

The examination for RN licensure is the same in every state in the united states. This examination: 1: guarantees safe nursing care for all patients 2: ensures standard nursing care for all patients 3: provides a minimal standard of knowledge for an RN in practice 4: guarantees standardized education across all pre-licensed programs

3

Which findings would indicate a need to refer a client to a health care provider when the nurse is screening clients for hypertension? 1: report of pain as the blood pressure cuff is inflated 2: systolic blood pressure result higher than 120 3:diastolic blood pressure reading greater than 89 4:loud korotkoff sounds as the blood pressure cuff is deflated

3

Which nursing action is most appropriate to help reduce the likelihood of an older adult client falling during the night? 1: moving the clients bedside table closer to the bed 2:encouraging the client to take an available sedative 3:instructing the client to call the nurse before going to the bathroom 4:assisting the client to telephone home to say goodnight to the spouse

3

Which response would the nurse give to the common statement "But you dont understand" when caring for an adolescent? 1: I dont understand what you mean 2: I do understand, I was a teenager once 3:it would be helpful to understand, lets talk about it 4: its you who should try and understand'

3

Which clinical finding demonstrates to the nurse that the client can use a standard walker? 1:weak upper arm strength and impaired stamina 2:weight bearing as tolerated and unilateral paralysis 3:partial weight bearing on affected extremity and kyphosis 4:strong upper arm strength and non-weight bearing on affected extremity

4

Which legal implication would the nurse understand about applying restraints to a client? 1: the law allows restraining clients until a written prescription is obtained 2:a felony charge may be leveled against nurses who use any kind of restraints 3:nurses are not obligated to report institutions that use restraints unlawfully 4:the nurse can be charged with assault and battery for using restraints improperly

4

How can the nurse evaluate the effectiveness of communication with a client? 1: client feedback 2: medical assessments 3:health care team conferences 4:client's physiological responses

1

Which Blood pressure would the nurse recognize as normal in toddlers? 1:84/54 2: 95/65 3:105/65 4:110/65

2: infants have the lowest blood pressure than toddlers

When conducting an assessment of a client who does not speak english and an interpreter is unavailable, which action would the nurse NOT utilize 1: using medical terminology 2:proceeding in an unhurried manner 3:speaking in a low and moderate voice 4:pantomiming words and simple actions while verbalizing them

1

The nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. Which step would the nurse do next after placing the nurses arms under the clients axillae? 1:bending and then straightening their knees 2:bending at the waist and then straightening the back 3:placing one foot in front of the other and then leaning back 4:placing pressure against the clients axillae and then raising their arms

1

Which assessment item needs to be documented on a client with restraints?select all that apply 1: pulse near the restrained area 2:temp of the restrained area 3:convenience of restraining the client 4:skin integrity surrounding the restraint 5:behavior leading to the need for restraint

1,2,4,5

Which findings indicate that the nurses are providing safe health care? Select all that apply 1:exhibit good decision making skills 2:acts within the scope of practice of their license 3:provides cost effective interventions to the clients 4:offers both curative and preventive interventions for the clients 5:executes interventions that have reduced the duration of hospital stays of the clients

1,2

Which interventions would the nurse manager include in a fall prevention program to decrease the number of falls on the unit? select all that apply 1:apply fall wristband 2:install bed safety alarms 3:establish a toileting schedule 4:allow client to ambulate to bathroom 5:use restraints to prevent the client from leaving the bed

1,2,3

Which signs and symptoms observed in the human body with a decrease in body temp? select all that apply 1:shivering 2:profuse sweating 3:flushed appearance 4: dilation of blood vessels 5:contraction of blood vessels

1,5: a client who has decreased body temp may experience shivering due to contraction of the blood vessels in body

A client who had an open reduction and internal fixation of a femoral neck fracture has a prescription for ambulation with slight weight bearing on the affected extremity. The nurse identifies that the client has kyphosis and strong upper arm strength. Which assistive device would the nurse expect the primary health care provider to prescribe?

1: crutches 2:quad cane 3:straight cane 4:walker

The nurse is caring for a two days post surgery hip replacement client who has had a bowel movement. Which nursing intervention would the nurse perform next? 1:provide perineal care 2:Turn and position the client 3:give a complete bed bath 4:document the bowel movement

1: providing perineal care (cleaning private areas) helps preserve skin integrity for the client who is incapable of providing self care.

Which action would the nurse take to decrease abdominal distention after a clients surgery? 1:encourage ambulation 2:give sips of ginger ale 3:provide a straw for drinking 4:offer an opiod analegesic

1:ambulation will stimulate peristalis, which increases passage of flatus and decreases abdominal distention.

The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia? Select all that apply. 1:dyspnea 2:flushed face 3:precordial pain 4:increased pulse rate 5:increased BP

2, 4: increased body heat dilates blood vessels, causing a flushed face. The pulse rate increases to meet increased tissue demands for O2 in the febrile state

A patient presents in the clinic with dizziness and fatigue. The assistive personnel (AP) reports a slow but regular radial pulse of 44. Place the following care activities in priority order. 1:Direct the AP to obtain a blood pressure 2:request that the patient lie on the clinical stretcher 3:assess the patients apical pulse for a full minute 4:prepare to administer cardiac stimulating medications

2,1,3,4

Which statements related to initial assessment of blood pressure by the nurse requires correction?select all 1: deflating the cuff too slowly will show false high diastolic readings 2:the stethoscope applied too firmly against the antecubital fossa will show a low systolic reading 3:if the blood pressure in the left arm is 110/80 and the right arm is 130/80, it is reportable 4: having the clients arm unsupported while assessing BP will result in a false low reading of BP 5:it is normal to have a blood pressure of 110/80 in the left arm and blood pressure of 120/80 in the right arm

2,4 -false low diastolic readings are obtained if the stethoscope is held too firmly against the antecubital fossa -keeping the arm unsupported while assessing BP results in false high BP

A nurse is instructing a client who has decreased leg strength on the left side on how to use a cane. Which actions indicate proper cane use by the patient? select all that apply 1:The patient keeps the cane on the left side of body 2:the patient slightly leans to one side while walking 3:the patient keeps two points of support on the floor at all times 4:after the patient places the can forward, he or she then moves the right leg forward to the cane 5:the patient places the cane forward 15-25 cm with each step

3,5

A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical record indicates tympanic temp of 38.7 at 4, 36.6 at 8, 36.9 at 12 and 37.6 at 3. How would the nurse describe this patter of temp measurements? 1: usual range of circadian rhythm measurements 2: sustained fever pattern 3: intermittent fever pattern 4: resolving fever patter

3:a pattern of fever where the body temp fluctuates from high to normal within a 24 hour period

Which measures would the nurse take to prevent skin breakdown for a confused client experiencing bowel incontinence? 1:answer the clients call light immediately to prevent incontinence 2:place a waterproof pad under the client to prevent soiling the linens 3:check the client's buttocks at least every 2 hours and clean after incontinence 4:offer toileting to the client every 2 hours to prevent incontinence

3:cleaning immediately after each episode helps prevent skin irritation by the digestive enzymes in stool

Which nursing interventions are beneficial in the event of fire in the hospital? select all that apply 1:opening the doors and windows 2:moving ambulatory clients in wheelchairs to a safe location 3:putting out the fire first and then removing the clients from fire area 4:asking ambulatory clients to help push wheelchair clients out of danger 5:maintaining injured clients respiratory status manually until removed from the fire area

4,5

A nurse prepares to contact a patients physician about a change in the patients condition. Put the following statements in order using SBAR (situation, background, assessment, recommendation) communication: 1:"she is a 53 year old female who was admitted 2 days ago with pneumonia and was started on levofloxacin at 5pm yesterday. She states she has poor appetite; her weight has remained stable over the past 2 days. 2:"the patient reported feeling very nauseated after her dose of levofloxacin an hour ago" 3:"is it possible to make a change in antibiotics, or could we give her a nutritional supplement before her medication?" 4:"the patient started to complain of nausea yesterday evening and has vomited several times during the night."

4: S 1: B 2:A 3:R

Which type of fever does a client have when experiencing fever spikes combined with a normal body temp occurring at least once a day? 1:sustained 2:relapsing 3:remittent 4:intermittent

4:characterized by fever spikes interspersed with normal temperatures

Which finding during a home health visit would prompt the nurse to provide a client with home safety instructions? select all that apply 1:area rugs on the floor 2:clogged, dirty fireplace 3:multiple electrical cords 4:multiple prescribed medications 5:wheeled walker with uneven legs

All of these are hazards -clogged fireplace:lead to carbon monoxide -polypharmacy can cause mental status change

Which strategies should a nurse use to facilitate a safe transition of care during a patient's transfer from the hospital to a skilled nursing facility? (Select all that apply.) 1. Collaboration between staff members from sending and receiving departments 2. Requiring that the patient visit the facility before a transfer is arranged 3. Using a standardized transfer policy and transfer tool 4. Arranging all patient transfers during the same time each day 5. Relying on family members to share information with the new facility

1,3

The primary health care provider prescribes thioridazine and assigns the nurse to monitor BP including assessment for orthostatic hypotension. Which intervention would the nurse perform? select all that apply 1:measuring the BP before dosing 2:reducing the dose if the blood pressure is low 3:measuring the BP 1 hour after dosing 4:measuring the BP 1 or 2 minutes after the client sits or stands 5:avoiding the measurement when the client is lying down

1,3,4

Which instructions to minimize the risk of falls in the home would the nurse provide the caregiver of an older client who requires the use of a walker with wheels? select all that apply 1:remove cords 2:apply bed alarms 3:use bright lightening 4:get ride of throw rugs 5:keep phone close by

1,3,4

When a nurse is making a home visit to a family with a toddler, which findings indicates a need for education about home safety? 1: fire extinguishers 2:unlocked cabinets 3:house built in 2000 4:front facing car seats

2

Which musculoskeletal changes directly place pregnant clients at increases risk for falls? select all that apply 1:back pain 2:joint laxity 3:weight gain 4:impaired balance 5:shifting center of gravity

2,4,5

Which response would the nurse make when obtaining a health history from a client who is known to be verbally abusive and says "youre ugly and youre probably stupid too. Why am I stuck with you"? 1: it does not matter what you think because I know I am a capable nurse 2:tell me more about why my caring for you today is so upsetting to you 3:if you like, I will arrange to switch assignments so you can have another nurse 4:you are talking inappropriately, so i am going to leave and will come back when you stop being verbally abusive

4: this response provides specific realistic feedback without rejecting the client

After recording the BP of a client, the primary health care provider confirms a diagnosis of pheochromocytoma.(increase production of hormones) Which blood pressure reading may have helped confirm the diagnosis? 1:90/70 2:80/60 3:120/80 4:190/90

4:the increase in blood pressure could be due to the increased production of catecholamines, indication endocrine imbalance

Which safety topic would the nurse include when providing information to parents of an 8 year old regarding bicycle safety? 1:helement use 2:hand signal 3:crossing signs 4:reflective lights 5:close toed shoes

ALL

The RN reviews the various sites for assessing body temp with unlicensed assistive personnel. Which UAPs statement reflects effective learning? select all that apply 1: the axilla is recommended to measure body temp in unconscious clients 2:the oral cavity is suitable for clients with epilepsy to measure body temp 3:the tympanic membrane is a preferred site of measuring body temp in infants 4:the rectum is a preferred site of measuring body temp in clients who underwent rectal surgeries 5:the temporal artery is a preferred site of thermometer placement to measure rapid changes in core temp

1,3,5

Motivational interviewing (MI) is a technique that applies understanding a patients values and goals in helping the patient make behavioral changes. When using MI, what outcomes does the nurse expect? select all that apply 1:gaining an understanding of the patients motivations 2:directing the patient to avoid poor health choices 3:providing assessment data that can be shared with families to promote change 4:identifying differences in patients health goals and current behaviors 5:recognizing the patients strengths and supporting his or her efforts

1,4,5

Which level of Maslow's Hierarchy of Needs is the nurse using when teaching the client about the call light system? 1:safety 2:self-esteem 3:physiological 4:interpersonal

1

Which quality is the most important tool the nurse brings to the therapeutic nurse-client relationship? 1:the self and a desire to help 2:knowledge of psychopathology 3:advanced communication skills 4:years of experience in the psychiatric nursing

1

Which situations are common negligent acts of nurses found in the hospital setting? select all that apply 1:failure to notify the health care provider of problems 2:failure to follow the 6 rights of medication administration 3:failure to ensure the safety of a client with disequilibrium probelms 4:failure to notify a family member about the clients current status 5:failure to administer medication during an emergency without consulting with the nursing manager

1,2,3

Which strategies will promote safety and quality of client care on the unit? select all that apply 1:Communicate with clarity and precision when designing multidisciplinary plans of care 2:create a safety huddle so all health care professionals are aware of the clinical objectives 3:emphasize electronic communication is quick and most effective means od sharing info in all situations 4:conduct communication simulations to increase knowledge about expertise of other health care disciplines 5:explain effective communication will take more time and effort compared with ineffective communication

1,2,4

Which intrinsic factor may contribute to falls in older adults? select all that apply 1:lack of exercise 2:impaired vision 3:inappropriate footwear 4:improper use of assistive devices 5:unfamiliar environment of hospital room

1,2: extrinsic factors are related to the environment and intrinsic factors are related to internal

The patient states, "I dont have confidence in my doctor. She looks so young." The nurse therapeutically responds: select all that apply: 1: tell me more about your concern 2:you have nothing to worry about. Your doctor is perfectly competent 3:you are worried about your care? 4:you can go online and see how others have rated your doctor. I do that. 5:you should ask the doctor to tell you her background

1,3

Which site would be safe and less expensive for temperature measurement of a human? select all that apply 1:skin 2:oral 3:axilla 4:rectal 5:tympanic membrane

1,3

When working with an older adult who is hearing impaired, the use of which techniques would improve communication? Select all that apply 1:Check for needed adaptive equipment 2:exaggerate lip movements to help the patient lip read 3:give the patient time to respond to questions 4:keep communication short and to the point 5:communicate only through written form

1,3,4

A client who had a right total hip replacement is progressing from the use of a walker to the use of a cane. In which hand would the nurse teach the client to hold the cane? 1: left hand 2:right hand 3:stronger hand 4:dominant hand

1:cane should be used on the unaffected side

Which factor would the nurse consider when counseling an older adult on how often to take a tub bath? 1:condition of the skin 2:ability of the client to provide self care 3:degree of orientation to the environment 4:type of allergic reactions experienced by the client

1:condition of skin is a priority for the frequency of bathing.

Which rationale would the nurse use to explain the canes purpose to a client with hemiparesis who voices a reluctance to use a cane? 1:maintain balance to improve stability 2:relieve pressure on weight bearing joints 3:prevent further injury to weakened muscles 4:aid in controlling involuntary muscle movements

1:hemiparesis creates instability. It also affects muscle strength, not joints.

A client with left sided weakness is learning how to use a cane. the nurse demonstrates proper use of the cane by holding it where? 1:on alternating sides 2:on the right side 3:on the side with weakness 4:on the side of their choice

2

The nurse is providing hygiene care to immobile client who was admitted for exacerbation of chronic obstructive pulmonary disease (COPD). Which nursing intervention is priority when the client becomes short of breath during the care? 1:obtain a pulse oximeter to determine the clients o2 saturation level 2:put the client in a high fowler position 3:darken the light and provide a rest period of at least 15 minutes 4:continue the hygiene activities while reassuring the client

2: this will help expands the lungs and decrease the severity of shortness of breath.

Which initial action would the nurse take when a client reports smoke coming from utility room on the nursing unit? 1:pull the fire alarm on the unit 2:remove anyone who is in immediate danger 3:obtain a fire extinguishes and report to the fire area 4:close all windows and fire doors and await further instructions

2:RACE - R:removing clients from danger

The nurse is changing the soiled bed linens of a client with a wound that is draining serosanguinous exudate. Which personal protective equipment would the nurse wear? 1: mask 2:clean gloves 3:sterile gloves 4:shoe covers

2:protect hands from microorganisms in the linens

Which method would the nurse teach a client on a rehab unit after cerebrovascular accident with residual hemiparesis (stroke) to help achieve the goal of safe walking with a cane? 1: shorten the stride of the unaffected extremity 2:advance the cane and the affected extremity simultaneously 3:lean the body toward the side with the cane when ambulating 4:hold the cane on the same side as affected extremity and increase the base of support

2:this supports stability. the body support occurs partially on the affected limb and partially on the cane as the unaffected limb moves forward

A client ask about the purpose of a pulse oximeter. Which measurement is a pulse oximeter used for? 1: respiratory rate 2:amount of oxygen in the blood 3:percentage of o2 carrying hemoglobin 4:amount of carbon dioxide in the blood

3

After teaching a group of new nurses about ways of making care visible, the nurse leader observes one of the nurses holding the hand of a client who was anxious before radiation therapy. which applied skill does the new nurse utilize to reflect effective learning? 1: expressing appreciation 2:using blameless apology 3:showing nonverbal care 4:making clear a positive intent

3

The nurse is working with a client who reports intimate partner violence and shares being afraid to leave the partner. Which info would the nurse discuss with the client to increase safety? 1: change the locks on the doors 2:avoid local area stores 3:develop an escape plan 4:obtain a restraining order 5:have important phone numbers

3,5 (the others are for when the client leaves the partner)