Fundamentals
A nurse is developing a plan of care for a client. Which of the following pieces of information should the nurse consider when planning care that is culturally congruent?
The meaning of disease can vary widely across cultures
A nurse is assessing a client who is undergoing a physical examination. Following the inspection, which of the following techniques should the nurse use next when assessing the clients abdomen?
auscultation
A nurse documents the presence of clubbing of the fingernails for a client who has emphysema. Which of the following is the underlying cause of this finding?
chronic hypoxemia ( clubbing of the nails of the fingers and toes is the result of chronic hypoxemia )
A nurse is conducting a health promotion class for a group of college students. Which of the following statements by a student should the nurse identify as a potential problem with achieving Eriksons development tasks for this age group ?
"I go home on the weekends to be with my family because I do not have any good friends here on campus"
A nurse is providing home safety instructions to a group of older adult clients. Which of the following statements by a client indicates an understanding of the teaching?
"I will put a night-light in the hallway"
A nurse is caring for a client who has cancer and refuses visitors because of his debilitated physical appearance. Which of the following comments should the nurse take?
"Would you like to talk about it ?"
While admitting a client to the medical unit, the nurse asks if he has advanced directives. The client states " I have a document with me that names someone who can make health care decisions for me if I am not able" the nurse should identify that the client is referring to which of the following documents .
Durable power of attorney document
What's the third step of correct use of fire extinguisher?
Squeezing the handle of the extinguisher
What's the second step of the correct use of fire extinguisher?
Aiming the hose of the fire extinguisher second step
A nurse is using I-SBAR communication tool to give a clients provider information about the client. The nurse should convey the clients pain status in which portion of the report?
Assessment
A nurse is taking clients vital signs. Which of the following findings should the nurse identify as outside the expected reference range?
BP 145/90 mmHg
A nurse is preparing to insert an indwelling unique catheter for a female client. Which of the following actions should the nurse have the client perform just before inserting the catheter ?
Bear down gently
A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client ?
Face the client when speaking
A client who report shortness of breath requests the nurse help in changing positions. After repositioning the client, which of the following actions should the nurse take next?
Observe the rate, depth, character of the clients respirations.
A nurse is performing a physical assessment of a client. Which of the following actions should the nurse take to assess the clients tissue perfusion?
Perform a blanch test
A home health nurse enters a client home and finds a used insulin syringe without a cap on the table. Which of the following actions should the nurse take?
Place the syringe in a puncture proof disposal container
A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. The nurse notes that the area of the arm immediately surrounding the insertion site is red and feels warm. Which of the following actions should the nurse taken ?
Remove the IV catheter
A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first?
Remove the safety pin from the extinguisher
A nursing is caring for a client who has peripheral edema. The nurse should identify that which of the following nutrients regulates extra cellular fluid volume ?
Sodium regulate extracelluar fluid balance nerve impulse transmission acid base balance and various others cellular activities
A nurse on a medical unit is caring for a client who has been coughing intermittently during meals, attempting to clear her throat repeatedly, and eating only a small portion of each meal. The nurse should recommend a referral to which of the following members of the interpersonal team to evaluate the client dysphasia?
Speech-language pathologist
What's the fourth step of correct use of fire extinguisher ?
Sweeping the hose from side to side to dispense material
A nurse is measuring a clients vitals signs. The clients heart rate is rate 105/min. The nurse should document this finding as which of the following alterations?
Tachycardia
A nurse is providing teaching to a client with heart failure about reducing his daily intake of sodium. Which of the following factors is the most important in determine the clients ability to learn new dietary habits ?
The involvement of the client in planning the change.
A nurse is developing a plan of care for a client . Which of the following pieces of information should the nurse consider when planning care that is culturally congruent ?
The meaning of disease can vary widely across cultures
