Final exam nur
The nurse provides care to a bedbound patient who is at increased risk for the formation of blood clot. When planning care for this patient, the nurse includes intervention to address which condition?
Thromboembolism
What is the purpose of assisting a patient to dangle?
To determine if the patient can tolerate changing positions
What is the most common area of Civil Law that affects nurses?
Tort
The nurse provides care to a patient who is able to do to nothing for self. Which type of care does the nurse include in the patient's plan of care?
Total care
Nursing care that crosses cultural boundaries or combines elements of more than one culture is called.
Transcultural nursing
Which assistive device will you is to assist a patient with mild right-sided weakness as he moves from the bed to the wheelchair?
Transfer belt
An embolism is the most preventable cause of death during hospitalization?
True
Failure to adapt to stress can lead to death
True
Hospitals, nursing homes and home health agencies must ask each patient if they have a living will or advanced directive.
True
Nonmagnetic stainless steel or titanium body piercings do not need to be removed prior to receiving a MRI.
True
One aspect of cultural competence is being aware of cultural differences.
True
Patient receiving TPN do not need to have their blood glucose/ sugar monitored.
True
The alarm phase of stress occurs when the body is first confronted with a threat.
True
When a person faces the complications of illness, trauma, or any medical condition, he/she may begin to question his/her faith.
True
When the body reaches the exhaustion stage of stress, the individual will get sick or die.
True
Which of the following nutrients cannot be digested and retain their original chemical identities in the body?
Minerals
The first role for women in health care was
Mode wife
The nurse provides care to a patient who is diagnosed with a loss of bone minerals. Increasing the risk of fractures. When planning care for this patients, the nurse includes interventions to address which conditions?
Osteoporosis
The Nurse Associated Alumnae of the United Stated had which purpose?
Oversee training to protect patients from incompetent nurses
A client from a non-English speaking culture is dying. Which should the nurse do to ensure that this client receives culturally specific care?
Ask if there are any specific cultural interventions at this time
A newly admitted patient with a diagnosis of a right sided weakness resulting from a cerebrovascular attack puts on her light and ask for assistance to the bathroom. You have not yet assessed this patient's transfer abilities. What will you do?
Ask the CNA to accompany you and together transfer the patient to the bedside commode
During lunch in the cafeteria, the nurse overhears two collogues discuss the care issues of a client. Which action should the nurse take?
Ask the colleagues to stop talking about the client in a public area
A client is using TENS unit for one hour to help relieve back pain. Which action should the nurse take after removing the unit from the client?
Assess pain level
The nurse provides care to a patient who begins to fall during ambulation. Which nursing action ensures safety for the nurse and the patient in this situation?
Allowing the patient to slide down the nurse's leg to the floor
A client makes an appointment at the health clinic to receive an annual influenza vaccination. Which health belief is this client demonstrating?
Biomedical
A patient vomits a large amount of coffee ground emesis, this indicates that.
Bleeding from the esophagus or stomach has occurred and mixed with stomach acid
What might be the outcome if you delegate a task to an unlicensed assistive personnel (UAP) or CNA that is not within his/her scope of practice?
Both you and the UAP/CNA can be in legal jeopardy
Which of the following would NOT be considered a medically necessary by an insurance company?
Breast implants to increase breast size
Nicole James, a 16 year old female, and weighs 97lbs. she has been exhibiting signs and symptoms over the past few months: diarrhea, dehydration, and frequent sore throats. Which of the following is most likely to be the source of her health problems?
Bulimia nervosa
The nurse gently squeezes the client's nailbed and counts the number of seconds until color returned to the nailbed. What is the nurse assessing in the client?
Capillary refill
The nurse is caring for a 9-year-old client who present with intense anal itching. The health-care provider administers an anthelmintic. Which condition does the client have?
Enterobius
You are caring for a patient with a nasogastric tube who us unable to take food or fluids by mouth. How often will you perform oral care for this patient?
Every 2 hours
How often during a continuous tube feeding should tube placement and residual gastric volume be asses?
Every 4 hours
A client received nutrition teaching from the RN. Which statement by the patient signifies that more patient teaching about the functions and importance of water in the body is needed?
Exercise does not affect eater intake unless I sweat"
The nurse is concerned that a client is experiencing stress. Which symptoms would the nurse assess in this client to makes this clinical determination?
Experiencing a backache for several weeks
A mechanical soft diet sometimes is ordered for patient's for sever weakness and fatigue. Which of the following nutrients is not abundant in this diet?
Fiber
The nurse witnesses a coworker taking a narcotic medication prescribed for a client. Which action should the nurse take first?
Report the incident to the nurse supervisor
The nurse is caring for a patient with difficulty breathing. With which health-care worker should the nurse collaborate to address this client's health program.
Respiratory Therapist
Bill Madison has been ordered to eat a pureed diet. Which food would you expect him to receive?
Scrambled eggs
The nurse is caring for the client with C. Dif. Which actions should the nurse take?
Wear a gown when caring for the client. Put on gloves before entering the client's room
Although there is no hard and false rule, when is the appropriate time to initiate hospice care?
When the patient is expected to live 6 months or less
In Fitzpatrick's conceptualization of health, a person's health is viewed as...
a dynamic state that changes continuously through a lifetime
A cost- efficient way to provide care to people who are confined to their homes because of illness or disability is to use of...
home health care
A patient who is terminally ill with cancer is no longer being treated with radiation or chemotherapy. The most appropriate level of care for this patient would be...
hospice
An RN student ask a friend who is an LPN/LVN student, "Will you be able to start IVs when you get out of school?"
it will depend on the Nurse Practice Act of the state where I work"
Diets modified by consistency include all of the following except...
low-sodium diet
Diagnosis-related groups (DRGs) are classifications of illness or procedures used to...
standardize the amount of government will pay for a specific illness
The primary function of carbohydrates as a food source is to:
supply energy
An LPN working in the hospital overhears a CNA mocking a patient for her beliefs that an evil spell has been cast on her, causing her illness. The nurse understands the need to...
take the CNA aside and explain that these words are insensitive to the patient's cultural belief
The circulatory effect of venous return is accomplished by bathing:
the extremities in a distal to proximal direction
At any given time, most of us are neither completely healthy nor completely sick. We have the capacity to be healthier and the potential to become very sick. This concept describes as...
the wellness-illness continuum
The bed bath supplies the nurse would plan for when caring for a patient are:
washcloths, towels, bath blanket and bath basin
Choosemyplate.gov recommends which of the following?
½- plate of fruits and veggies, 1/2 - plate grains and proteins, and a serving of dairy
Proper hand washing techniques requires that a nurse wash their hands for at least _____ seconds.
20
When a patient's immune system reacts to a food protein or other large molecules that has been eaten, this is known as:
A food allergy
The nurse is caring for a client in the hospital. On assessment, the nurse discovers the client's hands and feet are swollen. A review of the client's past medical history reveals a history of cardiac problems. Which diet does the nurse expect the physicians to order for this client?
A sodium- restricted diet
While bathing a client, the nurse finds that the client's previous IV site is tender, and the vein feels hard upon palpation, indicating inflammation. Which should the nurse apply to the site?
A warm compress using a washcloth dipping in hot water
A client who is admitted for observation following an episode of chest pain relieved by rest and two nitroglycerin tablets reports having a job as CEO of a large firm is becoming too much to handle.
According to Selye, what should the nurse suspect the client is experiencing? The exhaustion phase
The nurse reviews Healthy People 2020 with a client. What are the goals of this plan?
Achieve health equity and eliminate disparities, create social and physical environments that promote good health, promote quality of life, healthy development and healthy behavior
The new food labels now include which new information?
Added sugars
The nurse is completing the placement of a NG tube. Which is most reliable way for the nurse to initially confirm placement of the tube?
After placement of a radiopaque tube confirm the location of the tube by x-ray
A nurse would refrain from taking a blood pressure on which of the following areas?
Amputation od the arm, Mastectomy of the effected side, IV infusion on the selected
A client has developed a urinary tract infection after being cauterized during surgery. The nurse anticipates the health-care provider will prescribe an:
Antibiotic
A patient complains that he feels ill and the doctor told him it was a virus but the doctor would not give him any antibiotics. He's upset with the doctor. What is the reason for the health-care provider's actions?
Antibiotics only kill bacteria; they do not kill viruses
The mother of a 9-year-old client with a viral infection is demanding that the client be administered an antibiotic to treat the infection. Which is the most appropriate response?
Antibiotics would not be effective against a viral infection
A client skipping church because of not wanting to see certain people who might be in attendance on a holiday. Which defense mechanism did this client use?
Avoidance
Which assistive device would you use after a patient had fallen to help him/her return to bed?
Battery-operated lift
A client with a terminal illness is angry with God. Which intervention should the nurse use to address this clients spiritual distress?
Be present
A client with a sprained wrist is prescribed cold therapy. Which should the nurse explain about this treatment as compared to heat therapy?
Cold therapy decreases swelling and pressure on nearby nerves, which helps decrease pain. "
The nurse is taking care of a 78 year old male patient who is bedridden. Which type of bath would be appropriate for the patient?
Complete bath
The nurse provides care to the whole client, incorporating within that care the cultural context of the client's belief and values. Which type of care is the nurse providing?
Culturally competent
A client reports feeling pain "only when I move." Which type of pain is this client experiencing?
Deep Somatic
Which term should the nurse recognize for the process in which food is broken down in the GI tract, releasing nutrients for the body to use?
Digestion
A critically ill client may have difficulty in getting the restorative sleep necessary for healing. Which action should the nurse take to help this client?
Dim the lights and close the door
The nurse recognizes that the most common way for microorganisms to spread is through ____.
Direct contact
After cleaning a partial denture with metal parts, soak it in a denture cup with water containing a dissolved cleaning tablet.
False
After obtaining and measuring your patient's residual gastric volume, you will discard the contents in the toilet.
False
Coping strategies are unconscious reactions to decrease stress:
False
If you do not start eating, I will put a tube down your nose and feed you through it" is an example of battery.
False
Medicaid, the federal government's health insurance program for people older than 65 years of age.
False
Obtaining a blood sample without permission is an example of assault.
False
Research studies found that there is no relationship between an individual's religious beliefs or practices and his/her health.
False
The body is able to distinguish positive and negative stress.
False
Symptoms of food intolerance generally include which of the following?
Flatulence
The most famous kaiseworth was
Florence Nightingale
The vitamin that may help prevent fetal neural tube defects when consumed before pregnancy and through the early weeks of pregnancy is?
Folic Acid
A client tells the nurse of exercising minor GI pain, flatulence and diarrhea several times after meals. Which possible cause should the nurse identify?
Food intolerance
A character of saturated fats is that they are:
Found primarily in animal products
A 23-year-old female client has been diagnosed with a yeast infection. The nurse identifies that this is which type of pathogen?
Fungi
What is the main objective of the body's fight-or-flight response?
Get more oxygen to certain organs and muscles
A client has been vomiting without relief from medication. The physician orders the client on NPO status. Which action by the nurse violates the physician's orders?
Gives ice chips when the client indicates mouth dryness
What is most effective way to break the chain of infection and prevent health-care associated infections?
Hand Hygiene
The nurse is reviewing information about wellness prior to participating in a community health clinic. What should the nurse recall about Fitzpatrick's rhythm model?
Health is a state that results from environmental interaction
The nurse provides a client with a label from an ice cream container and asks specific questions about the information on the label. What is the nurse assessing in this client?
Health literacy
John Snow has a severe large pressure ulcer that the hospital is working to heal. What type of diet BEST meet the needs of this patients?
High-calorie, high-protein
A nurse delegates the task of assisting a patients with ambulation to a nurse assistant. The nurse intervenes when observing the nurse assistant implements which action?
Holds transfer belt loosely near that patient's body while ambulating
During an assessment, a client reports performing self-care techniques to balance the hot disease state of diabetes. Which health belief should the nurse realize that this client practice?
Holistic
A patient is placed on droplet precautions. You know his wife needs more teaching about PPE use when she says....
I don't need a mask if I stay a foot away from him."
A nurse reinforced education to a patient about how to avoid developing osteoporosis. Which statement indicates to the nurse a need for additional teaching?
I will remain in bed when I have a cold"
When educating a student about how to correctly logroll a patient, the nurse recognizes that additional teaching is necessary when the student makes which statement?
I will stand at the patient's feet and control the turn."
TRICARE for retired military personnel and their families and CHAMPVA for veterans are examples of...
Insurance for special population
The spouse of a client with terminal illness asks about hospice. Which information should the nurse include when responding to the spouse?
It is a program that focusses on palliative treatment and emotional support."
The nurse asked the case manager to explain the benefits a client on Medicaid has while hospitalized. What should the case manager explain about Medicaid?
It offers assistance for the poor and medically indigent individuals
a 17-year-old girl would be considered an emancipated minor in which of the following situations or conditions?
Marriage, In the U.S. Army, has lived alone and supported herself for 15 months.
The nurse reinforces teaching for the caregiver on an immobile patient who will be discharged home soon. Which caregiver action when supervising care indicates the need for the nurse to intervene?
Massage directly on redden bone prominences
Oatmeal would be given as a food choice for which mechanically altered diet?
Mechanical soft
A client has a federal government's health insurance program for people older than 65 years. Which type of health insurance should the nurses expect to see documented in the client's medical record?
Medicare
The nurse is presenting nutrition information to a client. The client states, "I know my diet is not the healthiest, but I never remembered to take vitamin supplements." Which response by the nurse reinforces good information for the client?
Most people get sufficient vitamins from plants, animal sources or supplements."
You and a CNA are preparing to turn an immobile patient from her back to her right side. Which of the following actions will you take first?
Move the patient to the left side of the bed
After providing morning care, the nurse forgot to put the bed in the lowest position and left one of the bed rails down causing the client to fall. For which reason could the nurse be reported to the board of nursing?
Negligence
A client recovering from an amputation asks why the foot that removed is causing pain. Which type of pain should the nurse explain that the client is experiencing?
Neuropathic
An infant is brought into a medical center and diagnosed with measles, a communicable disease. Which action should the nurse take?
Notify the health department
While caring for a patient, the nurse performed an intervention that is beyond the scope of practice. The nurse has violated the expectations of which regulatory body?
Npa
While caring for a patient, the nurse performs an intervention that is beyond the scope of practice. The nurse has violated the expectations of which regulatory body?
Nurse Practice Act
The charge nurse is concerned that client information was inappropriately shared with family. Which would the nurse observe to come to this conclusion?
Nurse left the computer screen with laboratory data in view at the bedside with family present.
Which is true of nursing car in hospitals during the 1700s and early 1800s?
Nursing care was provided by poor and lower classes
The nurse plans to care for a patient who has a history of becoming dizzy, pale, clammy and nauseated when moving from a lying position to a sitting position. The nurse plans interventions to prevent which condition?
Orthostatic Hypotension
What happens to the nervous system once the threat is removed and the fight-or-flight response is no longer needed?
Parasympathetic nervous system reverses fight-or-flight response
If you are assigned to bathe a patient, how should you respond?
Perform the bath as assigned, using it as an opportunity to further assess you patient
The nurse reinforces education to a patient who is at risk for thrombosis. Which patient action indicates correct understanding of the information presented?
Performing active rang-of-motion exercises
Which term does the nurse document in the patient's medical record for the movement of the intestines?
Peristalsis
Which term does the nurse recognize as the process of rhythmic, wavelike movements that begin in the esophagus and continue to the rectum to propel a bolus of food through the GI tract?
Peristalsis
What are some common reasons that the health-care provider would order a NG tube for gastric decompression?
Persistent vomiting, complete bowl obstruction and partial bowl obstruction
How will you provide stability as you assist a patient to stand before you begin ambulation?
Place your feet in front of the patient's feet and your knee against the patient's knee
A patient is extremely stressed and decides to decrease some of her responsibilities outside of her family and job. She resigns from being PTAA president and from being scout leader, as well as saying "no" to some church and social obligations. This is an example of using.
Positive coping strategies
The largest source of sodium in the typical American diets is?
Processed foods
A coworker says that she is not feeling well and is going to go straight to bed when she get off work. What phase of illness is your coworker experiencing?
Prodromal phase
Increasing one's fiber intake too much too quickly can have which of the following effects?
Produce excessive GI gas
Kwashiorkor is a type of malnutrition caused by an inadequate dietary intake of...
Protein
Tom Jones, a 67 year old male patient, has been on a liquid diet for several days and is expecting to remain on it for at least another week or two. What nutrients will the dietician most likely recommend be added to Mr. Gibson's diet?
Proteins and calories
The nurse is working in a critical care unit where the focus is on primary care nursing. Which action will the nurse take to demonstrate understanding od this care delivery approach?
Provide all aspects of nursing care for assigned patients
the nurse reviews a list of tasks to delegate to the UAP. Which should the nurse do first before assigning the task
Provide instructions to complete the task. Follow up to make sure the task was completed as directed. Identify the right task. Ensure the client is stable.
Which CAN action while making a bed for a patient who is out receiving therapy requires an intervention by the nurse?
Puts soiled linens on the floor
According to the joint commission, all patients have the right to?
Receive medical care considerate of their culture, religion, and spiritual being
A client who comes into the community clinic is experiencing adverse effects from using heroin for several years. To which facility should the nurse expert this client will be transferred?
Rehabilitation
When the nurse inserts a NG tube, the client becomes cyanotic, coughs incessantly, and is unable to speak. Which actions should the nurse take immediately?
Remove the tube completely
Which term does the nurse include in the plan of care for skin that slides over another surface in the opposite direction, which increases the risk of abrasions and open skin areas?
Shearing
Which of the following are examples of portals of exit in the chain of infection?
Sneeze of infected person, Bowel movement of infected person
The nurse is providing dietary teaching to a client who is vegetarian. Which is a single source of protein that the nurse should recommend to the client?
Soy
The nurse, who is working in a setting that has implemented interprofessional collaboration, asks the occupational therapist to adjust a client's device to promote self-care. Which response indicates that the care provider is practicing this approach to client care?
Sure, I can help."
A nurse encounters a bed made up with the tope linens fan-folded to the side of the bed. The nurse documents this as which type of bed.
Surgical
The instructor is reviewing the scope of practice for the LPN/LVN with a group of students. For which student's statement should the instructor provide more information about the role?
The LPN/LVN can practice independently."
The nurse applies a cooling blanket to a client with a temp. of 105.4 F. which should the nurse recognize as an indication of therapeutic effectiveness?
The Temp. slowly falls to 100F
The nurse is preparing to measure a client's blood pressure. Which should the nurse explain that blood pressure measures?
The amount of force being placed on arteries by blood
A client requests a copy of their medical records. Which response should the nurse make?
The chart belongs to the hospital, but if you give written permission, a copy can be made for you."
The nurse is caring for a adolescent client who is married, in the military, and has a new baby. Which should the nurse consider when providing care to this client?
The client can sign the informed consent form for a blood transfusion
The nurse is asked to explain the difference between core temp and the temp. measured through the tympanic route. Which response should the nurse make?
The core temp is more reflective of the environment the internal organs are being exposed to."
The nurse is discussing health with a client. What should the nurse explain about health being measured on continuum scale?
The higher the measurement is, the better one's health is
The nurse presents information regarding the Handle with Care campaign that was instituted by the American Nurses Association to new staff members. Which staff member statements indicates correct understanding of the information presented?
The purpose of the Handle with Care campaign is to build an industry-wide program in health care to prevent musculoskeletal injuries."
The primary function of protein in the body is to:
build tissue
For nutrients to be utilized, they must first be absorbed into the bloodstream from the GI tract. This is accomplished by uptake of the nutrients into the
capillaries located in the intestinal wall villi
While you are assessing a patient with a bed bath you notice a purplish blotching on the skin of the lower leg and feet. This is an indication of...
decreased circulation to the leg and feet
When did laws requiring licensing of nurses first come into being?
early 1900s
Dunns's Theory of high-level wellness includes the concept of health or sickness as it relates to an individual's...
environment
It is important to stay with a patient during the first bath or shower after surgery because the patient may...
experience vasodilation and become dizzy or faint