Fundamentals Final

Which procedure produces a surgical opening in the abdomen and bypasses the large intestine entirely?

illeostomy

Which vitamin should be suggested as a supplement to a client who chooses a vegetarian diet?

D

The nurse mixes two medications together in one syringe and is preparing to administer them to her patient. On entering the patient's room, the nurse notices that the medication looks cloudy and there are some particles floating in the mixture. What is the most appropriate action by the nurse?

Discard the medications and syringe.

A registered nurse administers the wrong medication to a patient. She does not notify anyone of the error and documents that the correct medication was administered. The nurse was reported to the state board of nursing. Which of the following actions can the state board of nursing take against the nurse in this situation?

Disciplinary action against the nurse's license to practice

A nurse discharges a client without answering any questions or teaching her how to treat a wound at home. What type of malpractice claim could be brought against this nurse?

Failure to implement a plan of care

The 17-year-old single mother of a 2-month-old infant comes to the clinic and tells the nurse, "Sometimes no matter what I do my baby won't stop crying. I hold him up in the air and shake him until he stops." Based on these statements by the mother, what is the first action by the nurse?

Teach the mother about the dangers of shaking a baby

Pain in feet when walking

problem of peripheral arterial circulation

Provide good foot care and prevent injury

promote peripheral arterial circulation

Apply sequential compression devices (SCDs)

promote venous return

Living in a healthy family is an important dimension of wellness. Which of the following most accurately describes a characteristic of healthy families?

A family in which individual members live a health-promoting lifestyle

What makes a nursing history different from a medical history?

A nursing history focuses on the patient's responses to the health problem.

Using the concept of the wellness-illness continuum, a nursing care plan for a chronically ill patient would outline steps to:

Encourage positive health characteristics within the limits of the specific illness

The nurse administered a narcotic analgesic to a client who underwent an amputation below the knee a week ago and reports phantom pain. Which statement best explains this type of pain?

Phantom pain is pain that the client experiences as a result of the amputated limb.

Which type of bowel diversion would result in a solid stool?

Sigmoid colostomy

A father brings his toddler to the clinic for well-child care. Which of the following would be most important for the nurse to assess?

Whether the home is childproof

The home health nurse is seeing an 80-year-old patient for the first time at his home. In developing a home plan of care, what is the nurse's highest priority for this visit?

Assessing the home for safety

Which of the following best explains the importance of standards of practice?

Standards of practice identify the knowledge, skills, and attitudes nurses need to provide safe care.

During the assessment process the patient states, "I am having numbness and tingling in my right arm." Which of the following best describes the patient's statement?

Subjective data

The PICO question reads, "Is TENS effective in the management of chronic low-back pain in adults?" Which part of this question comes from the "I" in PICO?

TENS

The nurse is caring for a client who is being discharged after sustaining a myocardial infarction. What is most important for the nurse to instruct the client?

Take stool softeners to prevent straining.

The preoperative phase encompasses which period of time?

The decision to have surgery until entry to the operating suite

Which factor most strongly affects the intensity of one's grief after a loss?

The meaning the person attaches to the loss

Who has the responsibility of obtaining informed consent prior to a procedure?

The surgeon

The nurse is looking for the most current evidence related to a newly FDA-approved medication. Which of the following sources provides the most current information?

The worldwide Web

The nurse would know care for a stage II pressure ulcer is achieving the desired goal when:

The wound bed contains 100% granulated tissue

Sources of simple carbohydrates

- Sugar - Milk

The nurse is performing a comprehensive health assessment on several clients in the community clinic. Which clients are most at risk for developing hemorrhoids? Select all that apply.

- A client with a history of constipation - A woman who has had four children

As a general rule, how much liquid soap should the nurse use for effective handwashing? At least:

3 mL

How long should the nurse auscultate each quadrant prior to documenting the absence of bowel sounds?

3 minutes

For which client would a long-term central venous device be most appropriate?

A 55-year-old client having twice-weekly chemotherapy treatments

Which client is demonstrating metabolic acidosis with partial compensation?

A client with a pH of 7.32, HCO3 of 28 mEq/L, and PaCO2 of 55 mm Hg

Which type of surgery is an appendectomy?

Ablative

Which is the definition of a "never event"?

An event that is a serious and costly error

Which dysrhythmia confirms death?

Asystole (absence of heart activity)

Which of the following is a correct developmental outcome for an infant? The infant's anterior fontanel (soft spot) typically fuses:

At about 14 months

Which instruction should the nurse be certain to include when providing discharge teaching for a patient who has a serious visual deficit?

Avoid using throw rugs on the floors.

Which action made by the client indicates a need for further teaching regarding use of the incentive spirometer?

Blowing into the device

Which class of nutrients is the body's primary source of energy?

Carbohydrates

A patient infected with a virus but who does not have any outward sign of the disease is considered a:

Carrier

A patient has a continuous IV infusion at 60 mL/hr. The right hand IV has infiltrated and the nurse has started a new IV on the left forearm. Which of the following interventions should the nurse also perform?

Change the administration set.

Which of the following is an example of a cluster of related cues?

Complains of nausea and stomach pain after eating

At the end of a guided imagery session, which physical assessment finding would suggest that the relaxation technique was successful?

Decreased blood pressure

Bronchovesicular breath sounds are best heard over which area?

First and second intercostal spaces next to the sternum

A patient with a history of seizures who takes phenytoin is at risk for which oral problem?

Gingival hyperplasia

Which of the following is an example of a complementary and alternative form of treatment or medicine?

Herbal medicines

The nurse is caring for a client with skin breakdown of the coccyx area. The physician has ordered a medication to be applied to the area. In applying the medication, the nurse is practicing which aspect of the Nursing Process?

Implementation

Which of the following is the most beneficial aspect of electronic documentation systems?

Improve legibility

Which theorist developed the nursing theory known as the Science of Human Caring?

Jean Watson

Which of the following is an example of an active listening behavior?

Leaning toward the patient

Which source of energy is butter?

Lipid

During a health history, a patient whose wife died unexpectedly 6 months ago in a motor vehicle accident admits that he drinks at least six bourbon and waters every night before going to bed. Which type of grief does this best illustrate?

Masked

What would be the most appropriate goal for a frail, elderly patient with a nursing diagnosis of Risk for Injury after hip surgery?

Remain free from injury or falls throughout hospital stay.

Identify the third step in the MORAL decision-making model.

Resolve the dilemma.

Which is a sensible fluid loss?

Urine output

Management of anticoagulation therapy

prevent clot formation

Which of the following is/are a benefit of bathing? Select all that apply.

- Increases depth of respirations - Provides opportunity for assessments

A patient has been admitted to the nursing unit with a diagnosis of chronic renal failure. She will be dialyzed for the first time tomorrow morning. Which of the following are appropriate nursing interventions for the patient? Select all that apply.

- Place the patient on strict I&O. - Weigh the patient before and after dialysis. - Maintain a total fluid restriction of 1,000 mL as prescribed.

The patient is diagnosed with obstructive sleep apnea. Identify the symptoms you would expect the client to exhibit. Select all that apply.

- Daytime fatigue - Snoring

Which physiological factors can place an 83-year-old client at risk for acute kidney injury? Select all that apply.

- Decline in glomerular function - Arteriosclerotic blood vessel changes

Which of the following medical conditions has a direct effect on sensory function contributing to sensory deficits? Select all that apply.

- Diabetes - Hypertension - Multiple sclerosis - Zinc deficiency

Which statement is accurate regarding electrocardiography (ECG)?

- An ECG reflects what the nerves tell the heart muscle to do.

The nurse is assessing the urinalysis results for a client with an indwelling urinary catheter. Which findings indicate the presence of a urinary tract infection? Select all that apply.

- Bacteria - Hemoglobin - Leukocyte esterase

A nurse is assessing an older client for orthostatic hypotension. What receptors would respond to a client's lowering blood pressures?

- Baroreceptors

A patient has started a fitness program. What program features illustrate that he has started a well-rounded program? Select all that apply.

- Flexibility - Balance exercises - Resistance training - Aerobic conditioning

The nurse educator is teaching a group of nurses who work in a senior citizens' center regarding fluid requirements for older adults. What should the nurse include in the session? Select all that apply.

- Fluid intake should be between 1500 to 2000 mL per day. - Fluid requirements should include noncaffeinated drinks. - Fluids should be increased when spending time outside in the heat.

Which describe symptoms of dehydration? Select all that apply.

- Thirst - Rapid pulse - Muscle fatigue

Bath water should be prepared at which temperature to prevent chilling and excess drying of the skin?

105°F (40.6°C)

The NHLBI panel of experts recommended that children between 9 and 11 years be screened for cardiovascular risk factors. What is the most important screening for this age group?

- Select lipid profile

An instructor asks the student nurse about common reasons for urinary incontinence. How should the student respond? Select all that apply.

- Sneezing and laughing - Overfilled bladder - Physical disabilities

Which of the following health information is protected in the electronic health record? Select all that apply.

- Social Security number - Insurance information - Laboratory results

Which are functions of the colon? Select all that apply.

- Water absorption - Vitamin absorption - Facilitate stool passage

Many older adults suffer from chronic health problems. Which of the following are the most common and costly chronic problems in the older adult? Select all that apply.

- Heart disease - Diabetes

Linda is recovering from arthroscopic knee surgery. Which nonpharmacological pain relief measures could be effective in treating her pain? Select all that apply.

- Heat and cold - Massage - Distraction - Immobilization

The nurse is evaluating a urinalysis for a client. Which items can be found on this report? Select all that apply.

- Hemoglobin - Protein - Glucose - Bilirubin

Which pain scales are used to determine a client's level of pain? Select all that apply.

- Numeric - FACES - Visual analog scale

How has the vast amount of information available on the Internet affected client-nurse relationships?

Clients actively participate in discussions about health issues and treatment options more often than in the past.

What is the deadline after admission for using the Minimum Data Set to evaluate a newly admitted resident is of a long-term care facility?

14 days

Which daily urine output is within normal limits for a newborn weighing 8 pounds?

180 mL

The nurse admits an older adult patient to the long-term care facility. When assessing for pressure ulcer risk, what should the nurse do after conducting the first Braden scale assessment?

Conduct another assessment in 3 days.

Nondirective interviewing is a useful technique because it:

Facilitates open communication

Which of the following reflects an understanding of the characteristics of older adults?

Fewer than 5% of all older adults live in nursing homes.

A patient has an area of nonblanchable erythema on his coccyx. The nurse has determined this to be a stage I pressure ulcer. What would be the most important treatment for this patient?

Frequent turn schedule

The nurse is preparing to insert a Foley catheter for her patient. What is the best strategy for the nurse to use to perform this insertion in a timely and efficient manner?

Gather all supplies and equipment before entering the patient room

Promote adequate hydration

Prevent clot formation

Which of the following interventions would be most appropriate for a patient who has an eye infection with moderate amount of discharge?

Using a different wipe to cleanse each eye

After identifying problems and etiologies and prior to writing a nursing diagnosis statement, the nurse would:

Verify the nursing diagnosis with the patient

The nurse overhears a coworker say, "How can an overweight nurse teach proper nutrition? That nurse should practice what is taught." Which concept best describes what the coworker is expressing?

Values

The student nurse is assigned to a patient through the entire perioperative period and identifies the time when the preoperative phase ends and the intraoperative phase begins as when the patient:

Enters the operating room

Donna would like a way to manage her pain on a long-term basis. She struggles with the emotions that come from living with chronic pain. Which pain intervention would be most beneficial?

Expressive writing

Which is an appropriate intervention for a client with a hearing deficit?

Face the client directly and speak loudly and clearly.

A client has called the nurse to the room several times over the course of the past hour because he or she keeps getting up and wandering and is having difficulty getting back into bed. On the last visit to the client, the nurse gives the client a sedative to cause drowsiness. What can this treatment be considered?

False imprisonment

The nurse notes an increase in the fluids removed with gastric suctioning. What electrolyte should be monitored more closely as a result?

Potassium

Which laboratory test result most accurately reflects a patient's nutritional status?

Prealbumin

Which type of managed care allows patients the greatest choice of providers, medications, and medical devices?

Preferred provider organization

Teratogenic drugs should be avoided in which patient population?

Pregnant women

The focus of nursing activities in the preoperative phase is to:

Prepare the patient mentally and physically for surgery

Turn client frequently, teach the importance of changing positions

Prevent clot formation

What is the purpose of antiembolism stockings?

Prevents deep vein thrombus and PE

The nurse assessing the mobility of a patient with Parkinson's disease might expect to observe which type of gait?

Propulsive

The nurse is performing a painless, noninvasive procedure to measure SaO2. Which procedure is it?

Pulse oximetry

A patient refuses a dose of medication. How should the nurse document the event?

Patient refuses the 0900 dose of digoxin.

The patient is just beginning to feel symptoms after being exposed to an upper respiratory infection. Which antibody would be most likely to be found in a test of immunoglobulin levels?

IgM

A 52-year-old man has a triceps skinfold thickness of 18 mm, and his weight exceeds the ideal body weight for his height by 23%. Which nursing diagnosis should the nurse identify for this patient?

Imbalanced Nutrition: More Than Body Requirements

The nurse is developing a plan of care for a patient admitted following a motor vehicle accident (MVA) who reports regularly sleeping only 2 to 3 hours per night. The patient says this is the third MVA he's been involved in this year. The patient thinks he might have been asleep when he got into the accident. What is the most appropriate nursing diagnosis for this patient?

Insomnia

Which outcome is appropriate for the patient who underwent urinary diversion surgery and creation of an ileal conduit for invasive bladder cancer?

Patient will perform urostomy self-care by (target date).

Upon initial assessment of a 75-year-old patient, you identify bruises and scratches on the patient's arms, legs, and trunk in various stages of healing. You notify your supervisor when you suspect the patient may be a victim of physical abuse. You are complying with which of the following state laws?

Mandatory Reporting Law

To provide the most analgesic effect, a medication should bind with and block the pain impulse especially at which of the following opioid receptor sites?

Mu

From what stage of sleep are people typically most difficult to arouse?

NREM, delta waves

According to the Institute of Medicine, which competency best promotes the concept of providing safe, quality client care?

Quality Improvement

Which is the most accurate method of verifying correct feeding tube placement when a tube is initially placed?

Radiography

The client's weight is appropriate for his height. His laboratory values and other assessments reflect normal nutritional status. However, he has told the nurse, "I probably eat a little too much red meat. And what is this I hear about needing omega 3 oils in my diet? I don't like to take supplements, and I think I could really improve my nutrition." Which of the following nursing diagnoses should the nurse use?

Readiness for Enhanced Nutrition

While reading a journal article, the nurse asks herself these questions: "What is this about overall? Is it true in whole or in part? Does it matter to my practice?" What is this nurse doing?

Reading the article analytically

After morning care, the nurse lowered the height of the IV container infusing via gravity flow, at the patient's request. What is the nurse's next best action?

Readjust the infusion rate, as needed.

A new father begins to hyperventilate as his baby is about to be born; he becomes light headed. The nurse instructs him to breathe into the paper bag until his breathing slows down. When he feels better he asks the nurse why using the paper bag helped him. What is the nurse's best response? "Breathing into the paper bag allowed you to

Rebreathe carbon dioxide to correct respiratory alkalosis"

Which describes the updated revision of vitamins, minerals, proteins, and total calories that are thought to meet the needs of about 98% of a particular group?

Recommended Daily Allowance

The nurse is caring for a patient with no spontaneous respiratory effort who requires mechanical ventilation. The first blood gas after initiating the ventilator shows a pH of 7.52 and a PCO2 of 20. What intervention is required to correct this pH imbalance?

Reduce number of breaths/min.

The nurse will know that the plan of care for the diabetic client with severe peripheral neuropathy is effective if the client

Remains free of foot wounds

For which of the following adult clients should the nurse make follow-up observations and monitor the vital signs closely? A client whose:

Resting morning blood pressure is 136/86, whereas the afternoon BP is 128/84 mm Hg

The nurse is developing a plan of care for a patient of Aleut descent who sustained a hip fracture. Which intervention by the nurse recognizes the patient's indigenous healthcare system and should be included in the plan of care?

Scheduling a visit from the local shaman

The nurse teaches a class for the community discussing routine screening tests for different types of cancer. What level of health prevention would the nurse classify this activity?

Secondary

Pain intensity words (adjectives) are used to describe pain. Which type of pain scale is this?

This simple descriptor scale

Which abnormal laboratory value is associated with an icteric sclera?

Bilirubin

A nurse is preparing to give a client an injection. As the nurse begins to give the injection, the client winces and withdraws. Which factor affecting sensory response does this demonstrate?

previous experience

What type of pain scale consists of a horizontal line delineating "No pain" on one end and "Worst pain imaginable" on the other?

the visual analog scale

Locations of fluid loss:

- Urine - Skin - Feces - Lungs

How often should the nurse provide tracheostomy care?

- Every 8 hours

The nurse is caring for a 55-year-old male smoker on the medical-surgical unit. The patient states, "I'd really like some help in quitting smoking." As part of her intervention plan she includes a smoking cessation class. What type of intervention is the nurse performing?

Wellness

Which of the following is an example of an open-ended question?

What happens when you have a headache?

The nurse is to administer an intravenous solution to a patient with diffuse edema. This will pull fluid from the interstitial space to the intravascular space. Which prescription would the nurse question for this patient? A prescription for:

5% Dextrose in water (D5W)

Which food provides the body with no usable glucose?

Wheat germ

A patient with a diabetic foot ulcer will need to perform dressing changes after discharge. When should the nurse schedule the teaching session(s)?

After the patient wakes up from a restful nap

Which of the following structures is considered a vestigial organ?

Appendix

How are short-term goals different from long-term goals? Short-term goals:

Can be met within a few hours or a few days

Which is an advantage of intermittent catheterization over indwelling catheters?

Can be removed immediately and client can void normally

The nurse in the emergency department admits a patient with a gunshot wound to the lower abdomen accompanied by heavy bleeding. What type of drainage does the nurse expect to see on the dressing?

Sanguineous

After receiving diphenhydramine, a patient complains that his mouth is very dry. This is not uncommon for patients taking this medication. Which drug effect is this patient experiencing?

Side effect

When inserting an indwelling catheter, which level of asepsis is used?

Surgical asepsis

In which way is pain positive?

Warns of bodily injury

Abdominal palpation should be avoided in a child who has which disorder?

Wilms' tumor

Which assessment finding made by the nurse confirms a client has a biliary obstruction?

white stool

The nurse is preparing a patient for a computed tomography (CT) scan of the abdomen. Which statement by the nurse is best? Assume all are true.

"You cannot have anything to eat or drink for 8 hours before your test."

Which of the following areas would the nurse include in a mental status assessment for an adult patient? Select all that apply.

- Behavior - Judgment - Knowledge - Appearance

Which statement(s) by the student nurse indicates an understanding of the nursing Kardex? Select all that apply.

- "It pulls data from multiple areas of the patient's chart." - "It summarizes the plan of care and guides nursing care."

Which disorder(s) might limit a patient's visual field? Select all that apply.

- Diabetes - Advanced glaucoma - Cataracts

What should the nurse document in the medical record for a client who had 14 respirations per minute that were unlabored?

- Eupneic

Acid-base balance is reflected through which arterial blood gas values? Select all that apply.

- PCO2 - pH - HCO3

Which recommendations to redesign the health-care system does the American Nurses Association's Health System Reform Agenda include? Select all that apply

- Shift the priority from illness care to health promotion. - Establish health policies that support safe, effective, patient-centered care. - Provide universal access to essential health-care services for all citizens and residents.

Which are the purposes of administering hypertonic IV solutions? Select all that apply.

- Stabilize blood pressure - Reduce edema - increase urine output

Hormones controlling fluid balance:

- Thyroid hormone - Antidiuretic hormone - Renin-angiotensin - Atrial natriuretic peptide - Aldosterone - Brain natriuretic peptide - C-type natriuretic peptide

The nurse gathers the following data: BP = 150/94 mm Hg; neck veins distended; P = 104 beats/min; pulse bounding; respiratory rate = 20 breaths/min; T = 37°C (98.6°F). What disorder should the nurse suspect?

Hypervolemia

Is a health program, administered by the state and funded by federal and state governments, to provide care for low-income people.

Medicaid

The nurse applies resistance to the top of the client's foot and asks him to pull his toes toward his knee. The nurse observes active motion against some, but not against full, resistance. How should the nurse document this finding?

Slight weakness

Which mineral can contribute to heart disease, hypertension, and stroke if consumed in large amounts?

Sodium

Why is it important to obtain information about nutritional and herbal supplements as well as about complementary and alternative therapies?

To identify potential interaction with prescribed medication and therapies

Which task can be delegated to nursing assistive personnel (NAP)?

Turn and reposition the patient every 2 hours.

Which type of surgery is performed within 24 to 48 hours to alleviate symptoms, repair a body part, or restore function?

Urgent surgery

Which diagnostic test should be obtained prior to surgery to determine if the client has an infection?

White blood cell count

The patient post-total knee replacement is preparing to be discharged. The patient tells the case manager, "I feel pretty good, but I am having a hard time getting in and out of the bathroom." What is the case manager's most appropriate response?

"An occupational therapist can be ordered to assist you in this area."

Which of these statements made by a client whose BMI is 34 and is attempting to lose weight would indicate the need for further teaching?

"An online food diary is unlikely to help me to improve my food intake."

The nursing student is caring for a seriously ill child on the pediatric unit. There are many family members present, including parents, aunts, and uncles. The student tells the primary nurse, "Every time I go into the room, everyone is shouting at each other, they shout at me, and they ask me the same questions over and over." What is the most appropriate response by the nurse?

"Families experience a range of emotions when caring for an ill member. Sometimes these are normal reactions, so you need not take it personally."

Which statement or question by the nurse indicates that the nurse-patient relationship is entering the termination phase?

"I'm leaving for the day. Is there anything I can do for you before I leave?"

A patient who had surgery 8 hours ago has not voided. The physician has prescribed that an indwelling urinary catheter be inserted. Which of the following statements should the nurse use to describe the procedure to the patient? "I need to:

"Insert a tube into your bladder to drain the urine because you haven't urinated since surgery"

While performing a physical assessment, the student nurse tells her instructor that she cannot palpate her patient's bladder. Which statement by the instructor is best?

"Palpate the patient's bladder only when it is distended by urine."

Which statement by the nurse best demonstrates clear communication to nursing assistive personnel (NAP) about delegating a task?

"Take the patient's temperature every 4 hours; notify me if it is greater than 100.5°F (38.1°C)."

A mother expresses concern that her 7-year-old has episodes of nocturnal enuresis approximately 3 to 4 times per week. The nurse's best response would be which of the following? Select all that apply.

- "Be patient; most children outgrow enuresis." - "You might consider purchasing protective pads for the bed."

The nurse meets with a patient with chronic pain who has tried a new program to manage pain. On a scale of 1 to 10, she reports pain reduction from an 8 to a 5. What questions would the nurse ask to further evaluate the effectiveness of this program? Select all that apply.

- "Does this reduction in pain allow you to perform daily activities?" - "Are you satisfied with the degree of pain relief you have achieved?" - "May I review what you have recorded in your pain journal?"

The nurse is obtaining her patient's health history related to infections. What are appropriate questions the nurse will ask the patient? Select all that apply.

- "Have you recently traveled out of the country?" - "How would you describe your current stress level?"

The parents of a 10-month-old infant with a cold ask the nurse about the use of honey to alleviate a cough. What is the nurse's best response?

- "Honey should not be given to children under the age of 1 year."

Which statements by the nurse demonstrate that active listening has occurred? Select all that apply.

- "I made eye contact and listened to my patient to find out his concerns." - "I sat with my patient and his wife to talk about their fears before the surgery." - "Using my own words, I restated what the patient was saying about his fears."

The nurse is teaching a pregnant woman about the increased oxygen demand that develops during pregnancy. The nurse knows the patient comprehends the teaching when she makes the following statement:

- "I may need to take an iron supplement so that I am not anemic."

A nurse is teaching a client who is started on digoxin before discharge. Which statements by the client indicate correct understanding of the teaching? Select all that apply.

- "I will take my pulse before every dose and contact my health-care provider for a pulse of less than 50." - "I will notify my health-care provider if I have blurred, yellow vision." - "My blood levels will have to be checked every month."

A nurse in the intensive care unit has been experiencing an excessive amount of stress in her workplace. She sees the employee health nurse and states, "I feel nervous and stressed all the time. Even when I go home, I don't feel better. What am I going to do?" What is the most appropriate response(s) from the employee health nurse? Select all that apply.

- "I'm happy to see you are here and asking for help dealing with your anxiety." - "Have you talked to some of your colleagues about the way you feel?"

A client is learning about anticoagulant therapy. Which statement indicates that the client understands this therapy?

- "If I am taking Coumadin, I will avoid green, leafy vegetables."

A day after abdominal surgery, a postoperative patient on a surgical unit says to the nurse, "I'm having a problem with a lot of gas. Maybe it's the food I'm eating." What is the appropriate response by the nurse? Select all that apply.

- "If the problem continues after you go home, you'll need to avoid gas-producing foods such as beans." - "Let's get you out of bed and walking more. This can help with your gas." - "When was your last bowel movement? You may be a bit constipated."

A client is concerned about the age-related changes of her mother, who is 80 years old. Which statement(s) made by the client would likely represent a normal change of aging? Select all that apply.

- "My mother seems to get cold very easily." - "My mother complains of her mouth being dry." - "Mother goes around the house turning on all the lights."

A 62-year-old man with emphysema says, "My doctor wants me to quit smoking. It's too late now, though; I already have lung problems." Which of the following would be the best response to his statement?

- "Once you stop smoking, your body will begin to repair some of the damage to your lungs."

Which blood pressure reading has a pulse pressure within normal limits? Select all that apply.

- 120/80 mm Hg - 130/86 mm Hg

The nurse is caring for a patient requiring a mechanical ventilator. When checking the inline thermometer, the nurse finds what temperature acceptable?

- 96°F

A nurse is learning about coronary artery disease. What is coronary artery disease?

- A condition where plaque builds up in the arteries that is a leading cause of cardiac ischemia

Which are examples of negligence? Select all that apply.

- A nurse not turning and repositioning a bedridden client, resulting in the development of bedsores. - A nurse not administering pain medications as needed for a hospice client. - A client falling after the client has called for assistance in getting up, for which nobody responded after 25 minutes.

Which statement(s) is/are most true about the concept of acculturation? Select all that apply.

- A person who accepts both his own culture and a new culture and adopts elements of each has been acculturated. - It is theorized that it can take years and even generations for an immigrant group to acculturate. - Acculturation is the outgrowth of a minority group's need to survive and flourish in a new culture.

The nurse is administering a purified protein derivative (PPD) test to a homeless client. Which of the following statements concerning PPD testing is true?

- A positive reaction indicates that the client has been exposed to the disease.

A nurse is teaching a group of clients about different cardiovascular medications. Which cardiac medications are considered vasodilators? Select all that apply.

- ACE inhibitors - Angiotensin II receptor blockers - Nitrates

The nurse is assessing a male patient diagnosed with chronic heart failure 10 years ago. Which finding would indicate poor perfusion to the tissues?

- Absence of hair on the lower legs and feet

Select the factors known to affect sleep. Select all that apply.

- Age - Environment - Lifestyle - State of health

The nurse has completed the plan of care for her patient with a medical diagnosis of Gall Bladder Disease. In selecting nursing interventions that will best serve to help the patient achieve the desired goals, the nurse will consider which of the following? Select all that apply.

- Age of the patient - Patient abilities and preferences - Education levels of the nursing staff - Medical orders

Which factors have led to a change in family living structures in the United States? Select all that apply.

- Aging population - Higher divorce rates - Socioeconomic factors - Older age at first marriage

When providing safety education to the mother of a toddler, you would inform the mother that, based on the child's developmental stage, he is at high risk for which of the following factors that influence oxygenation? Select all that apply.

- Airway obstruction from aspiration of small objects - Drowning in small amounts of water around the home

Which personal habits can increase surgical risk? Select all that apply.

- Alcohol abuse - Illicit drugs

A client with a diagnosis of dysrhythmias questions the nurse about the need for so many medications. The nurse explains the need for an antiarrhythmic to regulate the heart rate and rhythm. Which complications should the nurse explain to the client that can occur with untreated dysrhythmias? Select all that apply.

- Amplified risk of stroke - Decreased tissue oxygenation - Number of options

What is needed for perfusion to the tissues to be adequate? Select all that apply.

- An adequate circulation system with good blood flow - Oxygen-saturated hemoglobin traveling in the blood

Identify the desired effects of general anesthesia. Select all that apply.

- Analgesia - Amnesia - Muscle relaxation

In which ways can surgery or procedures contribute to sluggish bowel elimination? Select all that apply.

- Anesthesia - Stress - Decreased mobility - Manipulation of the bowel

The nurse is creating a plan of care for the reduction of the risk for clot formation. Which interventions should be included? Select all that apply.

- Apply sequential compression devices. - Turn the patient frequently or encourage frequent position changes. - Promote adequate hydration by encouraging oral intake. - Deliver anticoagulant medications as ordered.

Which of the following is/are accurate about nasotracheal suctioning? Select all that apply.

- Apply suction for no longer than 15 sec during a single pass. - Gently rotate the suction catheter as you remove it.

When performing a skin assessment, the nurse notices a mole on the patient's upper back. What are the appropriate actions by the nurse in further investigation of the mole? Select all that apply.

- Ask the patient about any new moles or changes in moles. - Measure the mole's diameter and elevation. - Assess for any exudate on or around the mole.

Which of the following principles apply when performing a focused assessment of the abdomen? Select all that apply.

- Ask the patient to empty his bladder prior to the assessment. - Position the patient in supine position with knees slightly flexed. - Begin palpating with light pressure to detect surface characteristics and move to deep palpation.

The nurse is caring for a patient with suspected kidney dysfunction. In reviewing the patient's home medication list, the nurse is most alerted to which medications? Select all that apply.

- Aspirin - Gentamicin - Ibuprofen

The nurse is caring for a patient who is wearing antiembolism compression stockings. The patient repeatedly complains of discomfort caused by the stockings. What actions will the nurse take to improve comfort? Select all that apply.

- Assess to determine whether the stockings are the correct size. - Ensure there are no wrinkles or rolled areas in the stockings. - Check that the stockings are on straight and the heel is in the right place.

A patient had a colon resection for removal of a cancerous tumor. Postoperatively, on the surgical floor which of the following activities would the nurse perform for the purpose of decreasing the risk of postoperative complications? Select all that apply.

- Assist the patient to turn, breathe deeply, and cough every 2 hours. - Assess the drainage from the surgical site. - Monitor vital signs on a regular basis.

Which of the following interventions has a public health focus? Select all that apply.

- Assisting with the launch of an after-school program in a high-crime neighborhood - Providing an influenza vaccination program for seniors and persons with chronic illness

The study of genomics and the use of a genogram are playing a larger role in personalizing a patient's plan of care. How are genomics and the use of a genogram helpful in personalizing a patient plan of care? Select all that apply.

- Assists in identifying at-risk individuals for certain conditions enabling better preventative care - Helps to more accurately detect illness, even before symptoms appear - Provides understanding of how people may respond differently to certain drugs and treatments

The nurse is caring for a client with untreated prolonged pain sustained in an automobile accident. Which assessment findings could result from the pain? Select all that apply.

- Atelectasis - Fever - Hypertension - Nausea and vomiting

Which of the following statements describe the proper technique for auscultating heart sounds? Select all that apply.

- Auscultate in an orderly fashion starting at the aortic area and proceeding to pulmonic, tricuspid, and mitral areas. - Use the diaphragm of the stethoscope for normal sounds the bell of the stethoscope to detect any extra sounds.

Which interventions are most important for the nurse to include in the plan of care for a client who underwent cardiac bypass surgery in order to prevent respiratory complications? Select all that apply.

- Auscultate lung sounds every 4 hours - Instruct on the use of incentive spirometer - Assist the client to ambulate the halls

The nurse is preparing to teach an older adult woman strategies to reduce the risk of osteoporosis. What will the nurse include as part of her teaching plan? Select all that apply.

- Begin a daily walking plan - Avoid cigarette smoking - Increase calcium in the diet

Which factors in a health history place a patient at risk for hearing loss? Select all that apply.

- Being an older adult - Frequent otitis media - Congenital rubella

Which of the following are examples of objective data? Select all that apply.

- Blood pressure reading 120/80 mm Hg - Moderate amount of yellow drainage from right ear

What are the parts of a comprehensive nutritional assessment? Select all that apply.

- Body composition - Physical assessment - Laboratory findings - Dietary history

The nurse is planning care for an elderly patient diagnosed with end-stage heart failure and a nursing diagnosis of Decreased Cardiac Output secondary to ineffective left ventricular function. What outcome would the nurse plan for this patient to measure improvement in cardiac output?

- Breath sounds clear with no shortness of breath

A healthy older adult comes to the clinic reporting fatigue when walking up stairs and doing her normal household activities. What anticipated physiological changes in the cardiovascular system occur with aging? Select all that apply.

- Cardiac contractile strength is reduced. - Heart valves become more rigid. - Peripheral vessels lose elasticity.

The nurse is giving a health promotion class for middle-aged males. As part of her teaching plan, the nurse will provide information on which common health problems associated with this age group? Select all that apply.

- Cardiovascular disease - Cancer - Obesity

Which are elements of the Good Samaritan law? Select all that apply.

- Care was provided in an emergency situation. - Care was voluntary and payment was not provided. - Care is provided in a reasonably competent manner.

Which of the following situations can lead to family caregiver's feeling(s) of "burnout"? Select all that apply.

- Caring for a teenager with schizophrenia - Caring for a spouse with Alzheimer's disease.

The nurse just finished inserting an indwelling urinary catheter into a client and is sitting down to document the procedure. Which information should the nurse include in the medical record? Select all that apply.

- Catheter size - Date and time of insertion - Amount of saline in balloon - Color, clarity, and amount of urine return

The nurse is providing discharge teaching for a client who will be taking a loop diuretic. What should the nurse include in the teaching? Select all that apply.

- Change positions slowly. - Report any muscle weakness. - Notify the health-care provider of any rash.

Mandy is collecting a urinary history for an older adult client admitted to the hospital with renal insufficiency and a urinary tract infection. What should be included in the questioning? Select all that apply.

- Changes in urinary habits - History of urinary infection - Frequency of urination - Fluid intake

Which actions by the nurse are considered "skilled nursing care"? Select all that apply.

- Changing a wound dressing - Monitoring an IV antibiotic - Teaching a patient how to use a blood glucose monitor

You are caring for a young adult patient with an intracranial hemorrhage secondary to a closed head injury. During your assessment, you notice that the patient's respirations follow a cycle progressively increasing in depth, then progressively decreasing in depth, followed by a period of apnea. Which of the following appropriately describes this respiratory pattern?

- Cheyne-Stokes respirations

Which factors should the nurse consider prior to selecting a vein for an intravenous (IV) catheter insertion? Select all that apply.

- Clients age - Type of solution - Speed of infusion

The nurse is planning to begin an animal therapy program for clients with chronic pain and is seeking administrative approval for this project. Which benefits of animal therapy should the nurse explain to the administration? Select all that apply.

- Clients report feeling better. - Clients have lower cortisol levels. - Clients require lower doses of pain medication.

A 24-year-old couple with two young children tell the nurse in the pediatric department that they have been struggling with raising them. They state, "We just don't know what we are doing sometimes and feel we are not always making good decisions for our children. It is time we sit down and figure this out." The nurse arrives at a nursing diagnosis of Family Processes: Readiness for Enhanced Parenting. Which nursing intervention(s) are most appropriate for this family? Select all that apply.

- Collaborate with family in problem solving and decision making - Encourage family members to verbalize concerns, fears, and perceptions.

The nurse is preparing to pass the 0900 medications prescribed for her patients. She removes the medications from the automated dispensing unit. When scanning the medication, an alert notifies the nurse that the patient is allergic to this medication. What action should the nurse take? Select all that apply.

- Confirm the patient's allergies and type of reaction. - Notify the prescriber of the patient medication allergy.

Older adults are more likely to use laxatives with regularity. In advising an older adult practicing this habit, the nurse would identify which of the following factors? Select all that apply.

- Consistent use of laxatives inhibits natural defecation reflexes, and is thought to cause rather that cure constipation. - Habitual use of laxatives may lead to the need for ever-increasing dosages until the intestine fails to work properly. - Laxatives may interfere with fluid and electrolyte balance.

An individual's response to stimuli is based on which factors? Select all that apply.

- Contrast - Adaptation - Previous experience - Intensity

Hardiness is a quality in which an individual experiences high levels of stress yet does not fall ill. What are the general characteristics of a hardy person? Select all that apply.

- Control - Commitment - Challenge

The new nurse is beginning her orientation on a medical-surgical unit. What is most important for the nurse to know regarding hospital policies concerning controlled substances? Select all that apply.

- Controlled substances are usually stored in a double-locked area. - The facility must keep a record of every dose of a controlled substance that is administered. - Handling and storage of controlled substances is regulated by the U.S. Drug Enforcement Agency (DEA).

A family assessment should include which areas? Select all that apply.

- Coping patterns - Health beliefs

The nurse is caring for a patient with an acute asthma event. What classification of medications would the nurse anticipate administering to this patient? Select all that apply.

- Corticosteroid - Bronchodilator

The nurse is reviewing laboratory data for a client who sustained a hip fracture and reports continuous pain. The nurse notices the client has a blood glucose level of 200 mg/dL, and the client has no history of diabetes mellitus. Which hormone release would cause hyperglycemia in the client? Select all that apply.

- Cortisol - Glucagon

The nurse is teaching a patient about the importance of reducing saturated fats in a cardiac diet. Which oils should the nurse recommend as options? Select all that apply.

- Cottonseed oil - Peanut oil - Olive oil

Which safety instructions should the nurse provide to the client using hot or cold for pain relief? Select all that apply.

- Cover the heating pad or hot pack with a towel. - Check skin frequently for color changes related to the heat. - Notify the health-care provider of any damage to the skin from hot or cold packs.

The nurse is implementing a wellness program based on data gathered from a group of low-income seniors living in a housing project. He is using the Wheels of Wellness as a model for his planned interventions. Which of the following interventions would be appropriate based on this model? Select all that apply.

- Creating a weekly discussion group focused on contemporary news - Facilitating a relationship between local pastors and residents of subsidized housing - Coordinating a senior tutorial program for local children at the housing center - Establishing an on-site healthcare clinic operating 1 day per week

The nurse is reviewing the laboratory data for a client admitted with acute kidney injury. Which values would the nurse expect to see elevated? Select all that apply.

- Creatinine - Blood urea nitrogen (BUN)

A nurse is assessing lab values for a client admitted to rule out myocardial infarction. What is the most sensitive test that measures damage in the heart muscle?

- Creatinine kinase-MB (CK-MB)

Which statement(s) about culture is/are true? Select all that apply.

- Culture exists on both material and nonmaterial levels. - Cultural customs change over time at different rates. - Culture is learned through life experiences shared by other members of the culture.

A patient has been diagnosed with hypovolemia. Which prescriptions for hydration should the nurse question? Select all that apply.

- D50W at 100 mL/hr - D5W solution at 100 mL/hr

Interventions for confused clients

- Decrease anxiety - maintain safety - promote orientation - provide continuity of care - simplify communication

The nurse is caring for a client in metabolic acidosis. With this condition, the nurse would anticipate which arterial blood gas changes? Select all that apply.

- Decrease in pH - Increase in CO2 - Decrease in HCO3

You are preparing the nursing care plan for a middle-aged patient admitted to the intensive care unit for an acute myocardial infarction (heart attack). His symptoms include tachycardia, palpitations, anxiety, jugular vein distention, and fatigue. Which of the following nursing diagnoses is most appropriate?

- Decreased Cardiac Output

The electronic health record (EHR) is used to document client care management. Which statement(s) below is/are applicable to EHR? Select all that apply.

- Decreases the time spent to complete documentation - Minimizes medical errors through use of alert systems - Communicates the client's plan of care to the healthcare team

A community health nurse prepares for a new assignment. She has been assigned census tracts 131 and 132. This large area crosses the border of two towns and includes 4,000 people. She recognizes that assignments are based on census tracts because census tracts do which of the following? Select all that apply.

- Define the geopolitical boundaries of a community - Divide populations into smaller groups that can be assessed more readily

The nurse is caring for a patient who had abdominal surgery 3 days ago and will be discharged home later today. The nurse will know that teaching is effective if the patient does which of the following? Select all that apply.

- Describes clinical findings associated with infection - Performs the dressing change as prescribed - Completes the regimen of prescribed antibiotics

The health-care provider instructs the nurse to force fluids of 2500 mL in 24 hours for a client with dehydration. Which interventions should the nurse include to meet this goal? Select all that apply.

- Determine the client's fluid preferences - Provide a cup with milliliter markings - Keep a pitcher of water at the bedside

Which actions would the nurse take when emptying the patient's closed-wound drainage system? Select all that apply.

- Don sterile gloves and personal protective equipment. - Inspect the drainage tube site and sutures. - Check that tubing to drainage system is intact. - Test the suction apparatus at prescribed pressure. - Document the color, type, and amount of drainage.

What are steps to help avoid malpractice? Select all that apply.

- Don't blame or criticize other health-care providers. - Recognize "problem" clients. - Recognize significant assessment cues. - Know and follow standards of care.

Which instructions should the nurse give to the patient complaining of constipation? Select all that apply.

- Drink at least eight glasses of water or fluid per day. - Gradually increase your fiber intake to 25 grams per day. - Use the restroom when you feel the urge to defecate.

Vitamins

- E - K - B12 - Thiamin - Riboflavin - Folacin

What should the nurse include in the teaching for a client with an ileal conduit urinary diversion? Select all that apply.

- Ensure the collection device fits snugly against skin. - Empty the ostomy bag frequently.

Which strategies are often effective in relieving anxiety and fear in clients with dementia? Select all that apply.

- Establish a predictable routine. - Use the same caregivers each day if possible - Use alternative therapies

Clients at risk for hypervolemia:

- Excess salt intake - Decreased cardiac output - Liver failure - Excessive IV fluid administration - Poor kidney function

The nurse is concerned that a client is in uncompensated respiratory acidosis. Which are possible reasons why the body is not compensating? Select all that apply.

- Excess sedation medication - Brain injury from a bleed - Blockage of the airway

The nurse is educating a client with chronic obstructive pulmonary disease (COPD) about deep breathing exercises. Which aspect should the nurse include for this client in particular?

- Exhale slowly through pursed lips.

You are caring for a patient with renal failure. His morning laboratory results reveal an abnormal potassium level of 6.8. This value is higher than it was on the previous day, when the level was within normal limits. You page the patient's provider, but he does not return your call right away. You become busy with another patient and forget to notify the provider again and fail to mention the critical laboratory value to the oncoming nurse during shift report. Which of the following does this scenario illustrate? Select all that apply.

- Failure to implement a plan of care - Failure to evaluate - Failure to assess and diagnose

Which of the following suggest that a family health problem may exist? Select all that apply.

- Family members enact decisions made by the most powerful member. - Family members do not consider that a conflict has been resolved until everyone agrees.

The nurse is preparing to write her nursing progress notes for a patient who has wrist restraints. Which of the following will the nurse include in her progress notes? Select all that apply.

- Family teaching initiated regarding the need for patient restraint - A prescription for wrist restraint received from the primary care provider

Which statements about grief are correct? Select all that apply.

- Grief is anticipated whenever there is a significant loss. - Grief can be detrimental to a person's physical health.

The nurse is assessing a client with a potential deep vein thrombosis (DVT). What sign does the nurse use by dorsiflexing the toes?

- Homan's sign

Which of the following groups represents a vulnerable population? Select all that apply.

- Homeless persons with no known illnesses - Women who have experienced domestic violence - Persons with type 1 diabetes mellitus

Which of the following questions would be effective for obtaining information from a patient? Select all that apply.

- How did this happen to you? - What was your first symptom? - When did you start having symptoms?

What teaching points will the nurse develop to address Healthy People 2020 goals? Select all that apply

- How to file for Medicaid - How to maintaining a safe home and neighborhood - How to develop and maintain a healthy lifestyle

The nurse is caring for a patient admitted with a diagnosis of muscular dystrophy resulting in inadequate muscle strength to draw enough air into the lungs. What nursing diagnosis would be most appropriate for this patient?

- Impaired Spontaneous Ventilation

What is the purpose of incentive spirometry following surgery? Select all that apply.

- Increases lung volume - Facilitates deep breathing - Promotes coughing

Which are complications of IV therapy? Select all that apply.

- Infiltration - Infection - Thrombus

The home health nurse is performing an initial assessment in the home of her 80-year-old client. Which of the following instructions will the nurse provide to minimize and prevent bathroom accidents? Select all that apply.

- Install grab bars in the bathtub or shower. - Use a nonskid mat in the bathtub. - Install a raised toilet seat.

Which medications would the nurse instruct the client with chronic constipation to avoid taking? Select all that apply.

- Iron - Opioids

Which points should the nurse include when teaching safety precautions to a mother of a toddler? Select all that apply.

- Keep the telephone number of the poison control center accessible. - Use a front-facing car seat placed in the back seat of the car.

A client is concerned about the cost of ongoing treatment and has asked about treatments that may be more affordable. What resources and information can the nurse provide to the client? Select all that apply.

- Listing of nurse practitioners who can provide equal care. - Information on complementary and alternative medicine (CAM) - Eligibility criteria for Medicaid

During the alarm stage of the general adaptation syndrome, which metabolic change(s) occur(s)? Select all that apply.

- Liver converts more glycogen to glucose. - Amino acids and fats are more available for energy.

Which are examples of adaptation? Select all that apply.

- Living next to train tracks and not being bothered by the sound of the trains after a period of time - Not hearing a loud ticking of a clock after hearing it over time

The nurse is caring for a client who has passed away, and the family is leaving the room after spending 30 minutes with the deceased client. Which processes would the nurse expect to find occurring in the deceased client? Select all that apply.

- Livor mortis - Algor mortis

Which of the following may cause grief and loss? Select all that apply.

- Losing a political party - Amputation of a toe - Demotion of a job position - Loss of a pet - Inability to have children

Which measures can be taken to prevent wrong-site, wrong-client, wrong-procedure surgical errors? Select all that apply.

- Mark the surgical site. - Use a preoperative checklist. - Perform a preoperative time out.

The nurse administers sublingual nitroglycerine, a vasodilator, to a patient diagnosed with angina. When the patient's chest pain is not relieved, the nurse prepares to give another nitroglycerine tablet. What is the nurse's priority action prior to administering the next dose of medication?

- Measure the patient's blood pressure.

Which factors could cause a person to develop a partial seizure? Select all that apply.

- Meningitis - Head trauma - Brain tumors - Sleep deprivation

The vascular system is composed of three types of vessels. What are capillaries?

- Microscopic vessels that connect the arterial and venous systems

Which of the following body systems must interact to produce mobility and locomotion? Select all that apply.

- Muscles - Skeleton - Nervous System

The nurse is preparing to apply a cardiac monitor to a patient. Where should the nurse place the electrodes?

- Near the indicated rib

What do negligence and malpractice have in common? Select all that apply.

- Negligence and malpractice are unintentional torts. - Malpractice is the professional form of negligence.

Which outcome statement is related to Decreased Cardiac Output? Select all that apply.

- No dyspnea or shortness of breath with exertion - Normal skin color - Brisk capillary refill

The nurse is caring for a patient with a chest tube. What outcome would indicate the chest tube can be discontinued?

- No further bubbling is seen in the water seal chamber.

Causes of urinary retention

- Obstruction - Medications - Inflammation - Neurological problems - Anxiety

The nurse is caring for a patient admitted to the hospital's hospice unit with terminal cancer and acute cancer pain. What factors does this patient have that will interrupt circadian rhythms? Select all that apply.

- Pain - Fear - Noise

What best describes general understanding of the concept of pain? Select all that apply.

- Pain sensation can be affected by a client's anticipation of pain. -Pain is an objective sign of a more serious problem. - Pain perception is different in every person. - Psychological factors often contribute to a client's pain perception.

Which statements about pain are correct? Select all that apply.

- Patients in pain rarely become addicted. - Patients can have severe pain and not exhibit any signs.

The nursing student is performing an otoscopic examination on her patient. In assessing the tympanic membrane, the student assesses for what normal findings in appearance? Select all that apply.

- Pearly gray - Shiny - Translucent

The nurse is teaching a patient about her chest drainage system. Which of the following should the nurse include in the teaching? Select all that apply.

- Perform frequent coughing and deep-breathing exercises. - Immediately notify the nurse if she experiences increased shortness of breath.

Interventions to improve smelling and tactile senses

- Place fresh fruit nearby - place fresh flowers nearby - hold a client's hand when giving bad news - use aromatherapy

Interventions to improve auditory senses

- Place hearing aids daily - confirm ears are clean - check hearing aids batteries regularly - place in quiet area - increase audio on television

For a patient with dementia, how might the nurse best improve orientation and clarity? Select all that apply.

- Place personal objects where the patient can see them. - Introduce yourself each time you have contact with the patient. - Use short sentences with only a few words. - Do not offer many choices when it comes to ADLs.

When using sterile technique to perform tracheostomy care of a new tracheostomy, which of the following is correct?

- Place the patient in semi-Fowler's position, if possible.

The nurse is planning care for a 70-year-old patient newly admitted with a medical diagnosis of pneumonia and a nursing diagnosis of Ineffective Airway Clearance. Which is the nurse's priority intervention?

- Position to optimize maximum ventilation.

Which types of mechanical stimuli that lead to pain would the nurse find in a client who is bedridden? Select all that apply.

- Pressure -Shearing - Friction

Which are goals of nursing care for a client with an indwelling urinary catheter? Select all that apply.

- Prevent infection - Maintain skin integrity - Maintain the free flow of urine.

Which are anticipated changes in the urinary system that occur with normal aging in the older adult? Select all that apply.

- Prostate size increases with age. - The number of functioning nephrons decreases with age.

Which are common gastrointestinal symptoms suggestive of food allergy? Select all that apply.

- Rash around the anus - Excessive gas - Intestinal bleeding

Which are effective ways of working through grief? Select all that apply.

- Recalling memories - Facilitating life review - Bibliotherapy - Expressing feelings

The patient tells the nurse, "I've always been able to maintain a steady weight by exercising and watching what I eat, but lately I seem to be steadily gaining weight." The nurse then collects a thorough sleep history. Why will the nurse ask the patient about her sleep habits? Select all that apply. Lack of sleep:

- Reduces activity levels - Increases appetite - Leads to poor glucose tolerance

Which actions occur to blood as it moves through the peritubular capillaries? Select all that apply.

- Removes ammonia from blood - Hydrogen ions secreted to help maintain normal blood pH - Removes creatinine from the blood

The nurse is caring for a client with diarrhea related to a virus. According to the BRAT diet, which foods should the nurse instruct the client to include in the diet? Select all that apply.

- Rice - Toast - Applesauce

Which factors place the patient at risk for constipation? Select all that apply.

- Sedentary lifestyle - High-dose calcium therapy

Interventions for communicating with the hearing impaired

- Speak to the client's "stronger" ear - don't speak while eating or chewing gum - don't shout - validate understanding - use visual cues - speak slowly and articulate clearly - use pen and paper when needed

What should be assessed when monitoring a client receiving parenteral nutrition? Select all that apply.

- Swelling, redness, drainage of insertion site - Rate and amount infused hourly - Blood glucose levels every 4 to 6 hours - Intake and output

The nurse is educating a group of clients in a community center about the use of over-the-counter pain medications such as nonsteroidal anti-inflammatory drugs (NSAIDs). What information would be most important to include? Select all that apply.

- Take NSAIDs with food or meals. - Use of aspirin can prolong bleeding time. - Use of ibuprofen is safer than prescription NSAIDs.

John is a 42-year-old being prepared for surgery. Which assessment findings could prevent the procedure from taking place? Select all that apply.

- Taking aspirin daily - BP 162/101 mm Hg - Dry, nonproductive cough - Temperature 100.2°F

The nurse is teaching a parent group of adolescent children about body piercings and tattoos. What is most important for the nurse to include in her teaching? Select all that apply.

- Tattoos and piercings can cause hepatitis. - Tattoos and piercings can cause skin infections.

During a thermometer exchange program at a local hospital, a person drops a mercury thermometer on the floor. Assume the nurse has been trained in cleanup of such a spill. How should the nurse intervene? Select all that apply.

- Using gloves and a paper towel, place the mercury in a plastic bag and dispose of it. - Wash her hands well after removing the spill. - Ventilate the area well for several days.

What should the nurse include when educating the parents of a toddler about safety hazards that can affect breathing? Select all that apply.

- Water safety - Choking on objects

The nurse is working with the family members who reports their elderly parent has decreased visual and hearing acuity. Which clinical manifestations should the nurse instruct the family to report? Select all that apply.

- Withdrawal - depression - hallucinations - social isolation.

Which of these steps in taking a blood pressure is/are correct? Select all that apply.

- Wrap the cuff snugly around the client's arm. - Have the client sit with feet flat on the floor.

Which hormone causes the kidneys to retain fluid?

Antidiuretic hormone

Which intervention is appropriate for the patient with a nursing diagnosis of Disturbed Sensory Perception: Gustatory?

Assess for sores or open areas in the mouth.

Which imbalance would be reflected by the ABG result of pH 7.35, PCO2 38, HCO3 18?

Compensated metabolic acidosis

The nurse assesses the following changes in a client's vital signs. Which client situation should be reported to the primary care provider?

Decreased blood pressure (BP) after standing up

Why is a lotion without petroleum preferred over a petroleum-based product as a skin protectant? It:

Decreases the risk of latex allergies

After a patient has an argument with her husband, she becomes verbally abusive to the nurse who is caring for her. Which coping mechanism is this patient exhibiting?

Displacement

As the nurse is assessing the hypotonic intravenous fluids, he realizes that the rate was not properly regulated and the client received 1,000 mL over 2 hours. What electrolyte imbalance is of greatest concern?

Hyponatremia

Which of the following most accurately describes nursing diagnoses? A nursing diagnosis:

Identifies a client's response to a health problem

What is the effect of physical activity on normal defecation?

Increased physical activity promotes normal defecation patterns.

A patient is admitted from a local skilled nursing facility to the outpatient surgery center for surgical debridement of a stage IV sacral pressure ulcer. The perioperative nurse discovers that the patient does not have a signed consent form for the surgery on the chart or in the surgery center. The patient says that she has not talked to the surgeon and that she has many questions regarding her surgery. When informed of this, the surgeon tells the nurse to have the patient sign the informed consent form, and he will review it prior to the surgery. What should the nurse do?

Inform the surgeon that she will have the patient sign after he discusses the surgery with the patient.

A patient who just returned from the postanesthesia care unit is complaining of severe incision pain. Which drug contained in his medication administration record will offer him the fastest relief?

Intravenous morphine sulfate

The primary focus of your interventions for a 6-year-old child who sleepwalks would be to:

Maintain patient safety during episodes of somnambulation

Which commonly accepted practice came out of the Framingham study? Use of:

Mammography in breast cancer screening

What is the purpose of using a sleep diary?

Note the trend in sleep-wakefulness patterns over a 2-week period.

The nurse hears rhonchi when auscultating a client's lungs. Which nursing intervention would be appropriate for the nurse to implement before reassessing lung sounds?

Request the client take a deep breath and cough.

Which assessment data best support a report of severe pain in an adult client whose baseline vital signs are within an average normal range?

Respiratory rate 26 breaths/min and shallow

When a patient has metabolic acidosis, which body system influences the acid-base imbalance to produce the compensatory changes in the arterial blood gases?

Respiratory system

Before administering a medication, the nurse must verify the six rights of medication administration, which include:

Right patient, right drug, right dose, right route, right time, and right documentation

Which test should the patient undergo when the Weber test is positive?

Rinne test

Which essential oil might the nurse trained in aromatherapy use to uplift and stimulate a patient?

Rosemary

Based on developmental stage, how should the nurse modify the comprehensive physical examination of an older adult?

Sequence the examination to limit position changes.

While assessing a new wound, the nurse notes red, watery drainage. How should the nurse describe this type of drainage when documenting?

Serosanguineous

An elderly patient tells the charge nurse that she wants another nurse to take care of her. When the charge nurse questions the patient, she states, "I don't want a man taking care of me." Which cultural barrier is this patient exhibiting?

Sexism

Which definition best describes a critical pathway?

Standardized plan of care for frequently occurring conditions

A client tells the nurse that she passes urine whenever she sneezes or coughs and it's quite embarrassing. How would the nurse describe this type of incontinence?

Stress incontinence

Which type of pain scale uses illustrations to help describe pain?

The Wong-Baker FACES pain rating scale

What is the recommended position for a patient who is experiencing an air embolus because of failure to prime the IV tubing?

Trendelenburg, on the left side

When making an occupied bed, which of the following is most important for the nurse to do?

Use a bath blanket or sheet to maintain patient warmth and privacy.

A client presents to the emergency room with third-degree burns to 25% of the body. Which fluid replacement would the nurse expect the health-care provider to prescribe?

Volume expanders

An individual who suffers from anorexia nervosa is at risk for what type of disruptions in the body?

Weakened immune system and hormonal imbalance

The nurse has a prescription to give medications "on call to OR." When should these medications be administered?

When the OR staff notifies the nurse to do so

Partially Compensated Respiratory Acidosis

pH < 7.35 PCO2 > 45 mm Hg HCO3 > 26 mEq/L

Elevate the legs above the level of the heart

promote venous return

patient is diagnosed with an intestinal infection after traveling abroad. The nurse should encourage the intake of which food to promote healing?

yogurt

Which statement by the patient demonstrates health literacy?

"I will take my medications after I ask the nurse a few questions."

A mother comes to the clinic with her 1-week-old infant for a newborn checkup. The mother tells the nurse, "My baby looks yellow to me." The nurse's best response is which of the following?

"The color is from the breakdown of maternal red blood cells."

To prevent a reduction in herd immunity, what should the nurse teach a class of pregnant women?

"You should ensure your child gets his or her immunizations at the recommended scheduled times."

The registered nurse is discharging a patient to an assisted living facility. Which instruction below is most appropriate for the patient?

"You will have assistance with meals and housekeeping tasks."

The nurse is caring for a patient diagnosed with pneumonia, teaching him or her how to cough and deep-breathe. The patient asks, "Why is drinking fluids so important?" What is the nurse's best response?

- "Fluids make secretions thin, making them easier to cough up."

The nurse is reviewing the structures of the heart. Which part is the pericardium?

- A sac of connective tissue that encases the heart

The nurse planning care for a patient after severe head trauma and long-term unresponsiveness considers which effect of immobility affecting the lungs? Select all that apply.

- Atelectasis - Pooled secretions

Sources of protein

- Eggs - Beef - Yogurt - Nuts - Kale

Select the process(es) that occur(s) during the inflammatory phase of wound healing. Select all that apply.

- Hemostasis - Inflammation

Sources of Unsaturated and Essential Fatty Acids

- Olive oil - Nuts - Salmon - Avocados

In which client would patient-controlled analgesia (PCA) be contraindicated?

A 75-year-old client with a history of Alzheimer's disease who fell at home

Which client is exhibiting third spacing of body fluids?

A client with increased ascites in the abdominal cavity

Which client would be at the highest risk for developing sensory deprivation?

A client with quadriplegia on bedrest

How does a nursing diagnosis differ from a medical diagnosis? A nursing diagnosis is:

A client's response to a health problem

Which type of client might be suitable for surgical interruption of a pain pathway?

A late-stage cancer client with intractable pain

What actions should the nurse take if he or she begins to have feelings of grief while caring for dying clients?

Acknowledge the grief and speak with coworkers who have similar job responsibilities.

Which of the following is the best example of a nursing diagnosis statement?

Acute pain related to out of bed activities

Which of the following is the best example of a well-written nursing order?

Administer pain medication 30 minutes prior to physical therapy exercises.

Which of the following best describes evidence-based practice?

An approach that uses the best scientific data to guide nursing practice

An older adult's fingernails appear concave and spoon shaped. The nurse associates this observation with:

An iron deficiency

Which surgical team member provides sedation and monitors client responses to surgery?

Anesthetist

Tim, a teenager, lands on his knee during a basketball game and it begins to swell. The nurse in the audience comes to assist with his discomfort. Which pain intervention would be most beneficial?

Application of cold

Katrina is experiencing lower abdominal cramping from her menstrual cycle. Which pain intervention would be most beneficial?

Application of heat

When the nurse is giving instructions for discharge, he notices that the television is on and he is eating a meal. The best thing for the nurse to do to ensure that the patient's discharge teaching is understood is to:

Arrange another time with the patient to review the discharge teaching

What is the primary reason the nurse incorporates pain assessment as a part of vital signs measurement?

Asking about pain may prompt patients to report pain more readily.

A home health nurse is working with a physical therapist and home health aides to work out a schedule for their visits that will best address the patient's needs. Which nursing role does this demonstrate?

Care coordinator

A patient who sustained a head injury in a motor vehicle accident has damage to the temporal lobe. This injury places the patient at risk for which type of hearing loss?

Central deafness

A nurse is teaching a client with heart disease about following a low-fat diet. Which foods would a nurse include in a list of high-fat foods to avoid?

Chocolate milk

Which of the following is the most common major challenge for older adults?

Chronic health problems leading to the loss of independence

For a cognitively impaired client who cannot accurately report pain, what is the first action that the nurse should take?

Closely assess for nonverbal signs such as grimacing or rocking.

While palpating the anterior chest, the nurse notes crackling in the skin around the patient's chest tube insertion site. The nurse recognizes this finding is:

Crepitus

The client with a diagnosis of multiple myeloma calls the nurse and reports pain of 9 on a scale of 0 to 10 and requests something for the pain. Which type of pain would the nurse document in the health record?

Deep somatic pain

How are critical pathways and standardized nursing care plans similar? Both:

Describe care common to all patients with a certain condition or situation

A 30-year-old male patient who has been experiencing joint pain for several months is diagnosed with rheumatoid arthritis. He tells the nurse, "This can't be happening to me. I don't understand this." Which statement below best describes the nurse's primary understanding of the patient statements?

Developmental stage influences a person's ability to cope with stressors.

A patient receiving an epidural analgesic complains of a headache. Which of the following should the nurse suspect?

Dural puncture

You are caring for a patient who suddenly experiences a cardiac arrest. As you respond to this emergency, which substance will your body secrete in large amounts to help prepare you to react in this situation?

Epinephrine

The pediatric nurse caring for a 3-year-old recognizes the most likely cause of sleep disturbances would be what?

Fear of monsters

Which polysaccharide is stored in the liver?

Glycogen

Which laboratory value would be increased when a client is dehydrated?

Hematocrit

Which type of lipid removes cholesterol from the bloodstream?

High-density lipids (HDLs)

Which of the following is true of synarthroses? Joints are:

Immovable

Which of the following provides evidence-based support for the contribution that advanced practice nurses (APNs) make within healthcare?

Improved patient compliance with prescribed treatments

A client arrives in the emergency department. He is pale and breathing rapidly. He immediately becomes unconscious and collapses to the floor. The nurse rapidly assesses the patient and decides the first series of actions that are needed. This scenario demonstrates:

Informal planning

A client presents with cyanosis, tachypnea, grunting, and reports that he or she cannot breathe. What is the immediate response the nurse should take?

Inspect to observe respiratory patterns and signs of respiratory distress.

The nurse notices that a patient has spoon-shaped, brittle nails. This suggests that the patient is experiencing Imbalanced Nutrition: Less Than Body Requirements related to deficiency of which of the following nutrients?

Iron

The nurse is caring for a client with diabetic ketoacidosis, an acid-base disturbance. What type of breathing pattern should the nurse anticipate?

Kussmaul's breathing

A client admitted to the inpatient medical-surgical unit has suffered sudden respiratory failure. The client's condition is getting worse; he is cyanotic (turning blue) with periods of labored breathing. What action should the nurse take first?

Look for an advance directive.

How can the nurse best provide teaching for a patient whose primary spoken language is not the same as hers?

Make arrangements to teach using an interpreter.

Which classification system promotes standardized language that will improve computer interoperability in nursing?

NANDA-I nursing diagnoses

A patient who underwent a left above-the-knee amputation reports pain in his left foot. The nurse should document this finding as what type of pain?

Phantom

The nurse is teaching a family about phantom pain. Which statement is correct?

Phantom pain is real and should be treated as such.

The primary care provider prescribes nitroglycerin 1/150 g SL for a patient experiencing chest pain. How should the nurse administer the drug?

Place the drug under the tongue and allow it to dissolve.

A nurses assess the client and develops a plan of care in which type of model of care?

Primary nursing

Encourage range-of-motion exercises

Promote venous return

Which nutrient deficiency increases the risk for pressure ulcers?

Protein

Which health-care worker would help the circulating nurse do a supply count throughout the surgical procedure?

Scrub nurse

Which professional nursing organizations would a nurse seek to join if interested in nursing research and scholarship?

Sigma Theta Tau International (STTI)

A client developed a stage IV pressure ulcer to his sacrum 6 weeks ago, and now the ulcer appears to be a shallow crater involving only partial skin loss. What would the nurse now classify the pressure ulcer as?

Stage IV pressure ulcer, healing

When caring for a patient with osteoporosis, which of the following is the most important action to take to minimize progression of the disease?

Start a weight-bearing exercise program.

The nurse working in an acute care setting provides what level of health prevention most often?

Tertiary

A patient who requires long-term rehabilitation needs which type of care?

Tertiary care

What important step could be called into question when reporting this incident?

The 30 minute delay in contacting the provider.

A client has a tendency to develop frequent constipation. Which dietary consideration should the nurse recommend?

The client should increase fiber intake.

Which statement is most reflective of Madeleine Leininger's theory of cultural care?

The goal of her theory is to guide research that will assist nurses to provide culturally congruent care.

Which of the following is true for goals/outcomes for collaborative problems?

They state that a complication will not occur.

Which statement describes the primary purpose of an incident report?

This report is used by risk management to prevent the incident from reoccurring.

Which of the following is an example of a school-age child's meeting psychosocial development tasks? The child:

Wants to buy the same jacket his friend has

Which step should the nurse take first when performing otic irrigation in an adult?

Warm the irrigation solution to room temperature.

Which of the following is an example of practical knowledge? Assume all are true.

When assessing the abdomen, you should auscultate before palpating.

A patient suddenly develops right lower-quadrant pain, nausea, vomiting, and rebound tenderness. How should the nurse classify this patient's pain?

acute

Normal Arterial Blood Gasses

pH 7.35-7.45 PCO2 35-45 mm Hg HCO3 22-26 mEq/L

Fully Compensated Respiratory Alkalosis

pH 7.40-7.45 PCO2 < 35 mm Hg HCO3 < 22 mEq/L

Pain, warmth, redness, and swelling of the calf or thigh on one side of the body

problem of clot formation

Which describes anything that triggers a nerve receptor, such as sight, sound, taste, or smell?

stimulus

Cuddling, feeding, and rocking an infant provide which type of stimulation?

tactile

A patient comes to the emergency department complaining of severe substernal chest pain. He is restless and anxious. Which statement by the nurse appropriately offers reassurance?

"I'll give you some medication to help relieve the pain."

The son of an 80-year-old patient tells the nurse, "I'm starting to worry about my father's eating habits. He lives alone and has been able to cook, but now he doesn't want to cook and says he is too tired to go to the store." What is the most appropriate response by the nurse?

"What are your feelings on using some community resources such as Meals on Wheels?"

The nurse is assessing an elderly male in the nursing home. What question will the nurse ask this patient to best assess his level of orientation?

"What is your name and today's date? Can you tell me where you are?"

The nurse is speaking with a client who is confused and is getting agitated. Which communication technique is most appropriate when the client asks about the whereabouts of his or her spouse who has been deceased for 3 years?

"You must miss your husband."

As the nurse caring for a patient who has suffered a myocardial infarction that has damaged the sinoatrial (SA) node, you should plan to monitor for which of the following potential complications? Select all that apply.

- Decreased heart rate - Decreased cardiac output

Which can occur as a result of sensory decline in older adults? Select all that apply.

- Depression - Social isolation - Hallucinations

What are the elements that the plaintiff must establish in a malpractice lawsuit? Select all that apply.

- Duty - Breach of duty - Causation - Injury

The healthcare providers said that Emma has experienced brain death. What does that mean for her physical functions? Select all that apply.

- Her heart is beating without artificial means. - Breathing requires a ventilator.

Which action is most appropriate for a client experiencing constipation? Select all that apply.

- Increase intake of fruits and vegetables - Increase intake of beans and legumes

What are some positive effects of pet therapy for residents in a long-term care facility? Select all that apply.

- Increases socialization - Decreases pain - Decreases loneliness

Which are examples of electrolytes? Select all that apply.

- Sodium - Potassium - Calcium

The parents of a 2-year-old child voice concern to the nurse that they are not able to toilet train the child yet. Which factors should the nurse explain to the parents that affect toilet training? Select all that apply.

- The child must be able to sense the urge to void. - The child must be able to remove his or her clothes. - The child must be able to voice the need to urinate.

Symptoms of dehydration:

- Thirst - Increased heart rate - Orthostatic hypotension - Increased blood pressure - Decreased urine output - Dry skin

Which interventions should the nurse include in the plan of care for a client who is disoriented to time? Select all that apply.

- open the drapes during the day - place some clocks in the client's room

A client asks the nurse which foods would help to consume 25 to 30 grams of fiber per day. Which foods should the nurse instruct the client to include in the diet? Select all that apply.

- popcorn - dried beans - raw vegetables - whole-grain breads

Which are ways the nurse can promote regular defecation for clients? Select all that apply.

- provide privacy - take a matter-of-fact straight forward approach - control odors to prevent embarrassment

Suzie, the nurse performing the grief and loss assessment on Philip, feels very uncomfortable asking personal questions. What could be some reasons for this response? Select all that apply.

-Fear of expressing emotion - Unresolved personal grief issues - Fear of her own mortality - Relating too much to his situation

Using Maslow's Hierarchy of Needs, rank the following nursing diagnoses in order of importance, beginning with the highest-priority diagnosis.

1.) Sleep deprivation 2.) Risk for infection 3.) Anxiety 4.) Disturbed body image

An adult patient admitted with lower gastrointestinal bleeding is prescribed a unit of packed red blood cells. Which gauge needle should be inserted to administer this blood product?

18 gauge

Of the following, which is the best choice for performing wound irrigation?

35-mL syringe with a 19-gauge angiocatheter

A patient has chronic confusion secondary to dementia. As a result, he is unable to sign an informed consent for surgery. In this situation:

A family member will be asked to sign the informed consent

Which represents an Americans with Disabilities Act (ADA) accommodation?

A nurse who has had a stroke is not physically able to perform client care and is given a position is scheduling, with an associated pay cut.

A patient had abdominal surgery. The incision has been closed by primary intention, and the staples are intact. To provide more support to the incision site and decrease the risk of dehiscence, it would be appropriate to apply which of the following?

Abdominal binder

Which movement of fluids and solutes requires energy?

Active transport

A patient who has been diagnosed with breast cancer decides on a treatment plan and feels positive about her prognosis. Assuming the cancer diagnosis represents a crisis, this patient is most likely experiencing which phase of crisis?

Adaptive

After receiving a course of chemotherapy, a patient begins losing hair. This adverse effect of chemotherapy should be documented as:

Alopecia

The Americans With Disabilities Act (ADA) defines a disability as a physical or mental impairment that substantially interferes with a person's ability to engage in major life activities. Among the various disabilities in the United States, which of the following is the most prevalent?

Ambulation

Which is a major factor regulating sleep?

Amount of light received through the eyes

A patient is to have a sequential compression device (SCD) applied on the postoperative unit. The patient is wearing knee-high elastic (antiembolism) stockings. When applying the SCD, what should the nurse do?

Apply the SCD over the knee-high antiembolism stockings.

A 42-year-old client has a rectal temperature reading of 39.2°C (102.6°F). Her blood pressure has decreased from 124/76 to 118/70 since taken 4 hours earlier. Her pulse rate has increased from 68 to 78. The nurse's initial best action is to:

Ask the NAP to obtain another set of vital signs in 4 hours

The nurse on night shift is caring for a patient who is confused and gets out of bed frequently. The nurse pushes him into a chair and states, "Do not get out of this chair or I will tie you up and leave you alone for hours." The nurse's action is an example of:

Assault and battery

A middle-aged patient with a history of alcohol abuse is admitted with acute pancreatitis. This patient will most likely be deficient in which nutrients?

B vitamins

Small hemorrhages are noted under the nailbed of a patient with a history of intravenous drug abuse. This finding is associated with:

Bacterial endocarditis

Which describes the measure of energy used while at rest in a neutral temperature environment that is required for the heart, lungs, and brain to function optimally?

Basal metabolic rate

Which of the following would be an instance to use a topical pain reliever?

Before giving an injection to a child

Which assessment finding made by the nurse warrants immediate health-care provider notification?

Brown-black

Who is the primary decision maker when caring for healthy adult clients?

Client

Which of the following nursing interventions is an indirect-care intervention?

Consulting

Ron is experiencing phantom pain after a left below-the-knee amputation.Which pain intervention would be most beneficial?

Contralateral stimulation

Which part of the kidney is made up of millions of functional units called nephrons?

Cortex

In informatics, raw, unprocessed numbers, symbols, or words that have no meaning by themselves are called which of the following?

Data

During digital removal of stool, which is the most serious complication the client is at risk of developing?

Decreased heart rate

The nurse is providing nutrition counseling for a patient planning pregnancy. The nurse should emphasize the importance of consuming which nutrient to prevent neural tube defects?

Folic acid

A client has hypovolemia as a result of excess blood loss from an abdominal gunshot wound. Which form of hydration would be most effective?

Isotonic fluids

Cardiac dysrhythmias have the potential to decrease cardiac output. Which type of dysrhythmia is located in the AV node?

Junctional

Which drug might the primary care provider prescribe to help facilitate pain management in a client with chronic pain?

Selective serotonin reuptake inhibitor

ICU psychosis occurs as a result of which situation?

Sensory deprivation

The nurse is caring for a client who has been in the intensive care unit for a week. The nurse notes that the client is experiencing restlessness, anxiety, and intermittent confusion. What could be contributing to the behavior changes?

Sensory overload

Which of the following examples includes both objective and subjective data?

The client's cholesterol is elevated, and he states he likes fried food.

A client asks the nurse for a laxative, as he or she has not had a bowel movement today. What is the first information the nurse should obtain prior to administering the laxative?

The client's normal bowel elimination pattern

Which factor can both support and hinder a person's ability to grieve the loss of a family member?

The family members have strong spiritual beliefs.

The nurse who is not assigned to care for the patient can access the patient's electronic health record in which circumstance?

The nurse is reporting lab results to the Code Blue team during resuscitation.

The nurse documents in the progress notes: "Admitted to emergency department accompanied by wife. Patient is alert and oriented, blood pressure is 120/80 mm Hg, and pulse is 80 beats/min. The patient is anxious. He becomes nervous and when asked about his smoking history." Which statement from the nurse's note is the best example of an inference?

The patient is anxious.

What is the goal of palliative care?

To provide comfort care to those whose illnesses are no longer curable

A nurse serving the community in a public health role would likely perform which of the following functions within a particular community?

Tracking the prevalence of gonorrhea between January and June

The nurse researcher is conducting a study. In preparation for the study, she will be developing a method for participants' identification while securing their privacy and confidentiality. What is the best method the researcher can use for participant identification and securing privacy and confidentiality?

Use a code number for each participant

During the bath, the nurse observed that the patient has dry skin. The best action by the nurse is to:

Use an emollient on the dry skin.

For the client with a stage IV pressure ulcer, what would an applicable patient goal/outcome be?

Wound will close with no evidence of infection within 6 weeks.

A patient complains to the nurse that since taking a medication he has suffered from excessively dry mouth. What term should the nurse use to document this complaint?

Xerostomia

Undigested food first enters the large intestine through which structure?

cecum

A nurse is auscultating bowel sounds on a client who has had recent abdominal surgery. She hears approximately 1 to 2 sounds per minute in each quadrant. Which condition should the nurse expect?

constipation

The nurse is assessing a client for circulation and perfusion problems. Which findings would indicate poor perfusion to the tissues? Select all that apply.

- Absence of hair on the lower legs and feet - Slowed capillary refill

A patient's blood group is B. The nurse knows the patient can receive blood only from donors with what group of blood? Select all that apply.

- B - O

The nurse admits a client with fever and chills. The nurse is concerned the client may have a urinary tract infection, so which other symptoms should the nurse ask about? Select all that apply.

- Back pain - Painful urination - Bladder spasms - Urgency

A nurse suspects a colleague is taking a client's narcotics. The colleague has been behaving erratically at work and his or her clients complain of uncontrolled pain. The nurse reports this concern to the colleague's supervisor. Which is this an example of?

Whisteblowing

For an unconscious patient, which of the following interventions are necessary to provide for patient safety? Select all that apply.

- Talk to the patient as you provide care. - Give frequent eye care if blink reflex is absent. - Keep the siderails up and bed in low position.

Which of the following interventions are best for preventing sensory deficit for a resident in a long-term care facility? Select all that apply.

- Talk to the patient as you provide care. - Incorporate touch when providing care.

The nurse is caring for a patient after abdominal surgery and notices that his urine is blood tinged. She places a call to the physician regarding the color of the urine. When communicating to the physician using the SBAR format, which statement by the nurse below best describes the "R" in SBAR?

"Your patient has blood-tinged urine after surgery. I suggest that we obtain an urinalysis for this patient."

Which nursing degrees are research-focused? Select all that apply

- Doctor of Nursing Science (DSN?DNSc) - Doctor of Philosophy (PhD)

Which strategies might be effective at preventing sensory overload in ICU clients? Select all that apply.

- Keep lights low at night - Reduce sounds in and around the area. - Limit the number of times the client must be awakened.

Where in the body is glucose stored? Select all that apply.

- Liver - Skeletal muscles

What are the three classifications of analgesics? Select all that apply.

- Nonopiods - Opiods - Adjuvants

Which healthcare team members are involved in hospice care? Select all that apply.

- Social workers - Therapists - Clergy

Which is a normal specific gravity for urine?

1.02

A nurse is teaching wellness to a church group. How many daily 8-ounce servings of water should be encouraged for normal bowel health?

6-8 servings

Which statement below best describes the difference between a "DNAR" and an "AND" order?

AND contains the word death, so the intent of the order by the provider is clear.

Which electrolyte is found primarily in bones and teeth?

Calcium

The nurse is caring for a patient newly diagnosed with narcolepsy. What is the priority teaching point the nurse would share with the patient?

Do not drive or operate heavy equipment.

The primary nursing intervention for an older adult who is a victim of abuse is to:

Ensure the safety of the victim

According to Maslow's Hierarchy of Needs, the nurse's primary focus in caring for a homeless family is:

Food and shelter

For which of the following patients would it be most important to obtain an apical-radial pulse and calculate the pulse deficit? A patient who:

Has a heart or lung disease

The nurse is teaching a class for diabetics and tells them, "Maintaining your blood glucose within normal limits helps reduce the risk for complications of diabetes." What type of activity does this class represent?

Health protection

The nurse is providing prenatal counseling for a couple who is trying to become pregnant. The priority for the nurse is to include which of the following information?

Healthy eating habits before and during pregnancy

The nurse is reviewing laboratory values for a client admitted with the following laboratory data: HCO3 20 mEq/L pH 7.30 PaCO2 60 mm Hg. How would this be documented in the client's medical record?

Metabolic acidosis

A physician tells a patient that she has cancer and that she should have surgery as soon as possible. The patient is not certain she wants to pursue this treatment approach, but responds by saying, "I'll do whatever you think I should do." Which communication style is this patient using?

Passive

Which action should the nurse take to assess a 2-year-old child for pinworms?

Press clear cellophane tape against the anal opening at night to obtain a specimen.

A patient fractured her right ulna 8 weeks ago and has just had her cast removed. The orthopedic surgeon prescribes isometric exercises for the right arm. Which of the following exercises complies with the surgeon's orders?

Press the right hand against a wall; hold this position for 6 to 8 seconds, and repeat 5 to 10 times.

Which nutrients are needed to repair and maintain cells?

Proteins

Which of the following is the principal site for regulation of fluid and electrolyte balance?

Renal system

Which acid-base imbalance is present when a client's ABG shows a pH of 7.27, PCO2 of 55, and HCO3 of 24?

Respiratory acidosis

The nurse is developing a plan of care for a client with new hearing aids. Which long-term goal is most appropriate for the client?

The client will demonstrate how to properly care for the hearing aids within 2 weeks.

A new mother asks the nurse about the importance of breastfeeding her infant. What is the best response that the nurse can provide as the primary reason?

The nutritional quality of breast milk remains consistent regardless of dietary intake so that infants will receive all needed nutrients.

What happens to pH when there is full compensation?

The pH returns to normal.

The patient tells the nurse, "After a couple of glasses of wine I sleep very soundly." After assessing further about the patient's alcohol history, what response by the nurse is most accurate?

"What else do you do on a regular basis that helps you to fall asleep and stay asleep?"

Symptoms of fluid overload:

- Bounding pulses - Hypertension - Tachycardia - Tachypnea - Jugular vein distention (JVD)

The nurse has completed an external genitalia examination on several female clients in the women's health clinic. Which of the following clients would require an internal genital examination? Select all that apply.

- Client on hormone therapy - A client with an abnormal finding on the external examination

The nurse is providing comfort to a person who has fallen on the hiking trail and broken his ankle. Which techniques can be used until medical help arrives? Select all that apply.

- Massage - Controlled breathing - Meditation - Imagery - Relaxation

Which functions of the kidney are considered secondary functions? Select all that apply.

- Renin production - Vitamin D activation - Erythropoietin secretion

Identify the normal range of pH.

7.35 - 7.45

What is the best description of the Nursing Process? The Nursing Process is:

A systematic process for the delivery of nursing care

The nurse is admitting a 70-year-old Hispanic female to the medical floor. Upon her arrival, the nurse notices that the woman speaks very little English and does not appear to understand what the nurse is asking. What is the most appropriate action by the nurse?

Activate the hospital's translating system and obtain a translator, if available

Which intervention takes priority for the patient receiving hospice

Administering pain medication to keep the patient comfortable

The nurse enters the client's room and before he can take vital signs, he hears a piercing, high-pitched sound coming from the client when he breathes. The nurse's initial next best action is to:

Assess the client's airway patency

Which electrolyte is often given as a supplement to elderly people to reduce the risk of fractures and osteoporosis?

Calcium

An older adult receiving hospice care has dementia as a result of metastasis to the brain. His bone cancer has progressed to an advanced stage. Why might the client fail to request pain medication as needed? The client:

Cannot communicate the character of his pain effectively

A patient's catheter bag is empty 2 hours after it was last drained. The nurse's first action is to:

Check for kinks or compression

The nurse is reviewing a client's home medication profile prior to surgery. Which medication taken by the client may impede postoperative wound healing?

Corticosteroids

Clients with private insurance pay for services in the form of deductibles, premiums, and co-payments in which method of financing health care?

Cost-sharing

The nurse organizing an Evidence-Based Practice Committee has a computer with Internet access. What else would be most important to the committee when searching for the most current scientific evidence?

Database of health journals

A patient dying of heart failure has changed his choice about his end-of-life treatment measures several times. He says, "I just can't make up my mind about it." Which nursing diagnosis is most appropriate for this patient?

Decisional Conflict

An 85-year-old patient is brought to the emergency department with lethargy and hypotension. When the nurse assesses the patient's tongue, she notes that it appears dry and furry. This finding suggests:

Dehydration

The nursing diagnosis is: Impaired Memory related to fluid and electrolyte imbalances AMB inability to Knowledge recent events. Which of the following goals/outcomes must be included on the care plan?

Demonstrates use of techniques to help with memory loss

A client newly diagnosed with diabetes is admitted to the hospital because her diabetes is out of control. Which of the following is an appropriate direct-care intervention for this client during her stay?

Demonstrating blood glucose monitoring and insulin administration to the client

A Spanish-speaking patient in the hospital is getting ready surgery and needs to sign the surgical consent form. Existing regulations determine the healthcare organization's responsibility for obtaining informed consent from this patient. The healthcare organization is required to do which of the following?

Ensure adequate resources to comply with informed consent requirements

What is one advantage of problem-intervention-evaluation (PIE) charting?

Establishes an ongoing plan of care for the client

Which type of health promotion programs seeks to raise the level of knowledge and awareness of individuals and groups about health habits?

Information dissemination

The nurse is assigned to the care of the following patients. In planning nursing care, the nurse knows she should use touch cautiously, especially when communicating with which patient?

Older adult admitted with dehydration with a history of dementia

The most obvious reason for using a framework when assessing a patient is to:

Organize and cluster data

By which method is water absorbed by the small intestine and the colon?

Osmosis

The nurse is caring for a client who was just brought to the postanesthesia care unit. Which assessment finding made by the nurse requires immediate intervention?

Oxygen saturation of 78%

Which describes the duration or intensity of pain a person can endure?

Pain tolerance

Premature babies are at higher risk for what respiratory problem?

Respiratory distress syndrome

Which part of the brain controls consciousness and alertness?

Reticular activating system

The home health nurse enters the apartment of an elderly client who lives alone and immediately determines the client has a hearing impairment. Which finding supports this conclusion?

The television is on very loud in the same room as the client.

Which consequentialist theory requires a risk-benefit analysis?

Utilitarianism

Which concept involves the movement of air in and out of the lungs through the act of breathing?

- Ventilation

Which client is at highest risk for developing postsurgical complications?

75-year-old pneumonia client

In a healthy adult, which of the following regulate body fluids? Select all that apply.

- Hormone levels - Fluid intake - Kidney function

The nurse asks the patient to spread his fingers and then bring them together again. Which of the following is the nurse testing when asking him to bring his fingers together?

Adduction

Which prescription below is not consistent with the standards established by The Joint Commission?

Administer Lasix 10.0 mg PO daily at 1000.

The nurse reassesses the client 30 minutes after administering a narcotic analgesic and notices the client has a respiratory rate of 6 breaths per minute. What should be the nurse's first intervention?

Administer a dose of naloxone (Narcan).

The nurse receives a laboratory report that states her patient's digoxin level is 1.2 mg/mL; therapeutic range for this drug is 0.5 to 2.0 mg/mL. Which action should the nurse take?

Administer the next dose as prescribed.

Which patient teaching would be most therapeutic for someone with sleep disturbance?

Do not go to bed feeling upset about a conflict.

Which of the following best reflects the definition of the Uniform Determination of Death Act?

Irreversible cessation of brain and brainstem function

The inhabitants of Yulupa, California, form which of the following?

Population

The nurse witnesses the patient's signature on a consent form to participate in her physician's research study. After the physician leaves the room, the patient tells the nurse she really doesn't want to participate but didn't have the heart to turn down the request because of fear that the physician would be upset. What should the nurse do to advocate for this patient?

Tell the physician why the patient agreed to participate.

Which body systems will attempt to keep the body in homeostasis if acid-base imbalance continues for an extended period of time?

- Kidneys - Lungs

Which are sources of fluid loss in the body? Select all that apply.

- Urine - Skin - Lungs

The nurse is caring for a client with heart failure. She begins to obtain the client's history and vital signs and then listens to breath sounds. The nurse is practicing which aspect of the Nursing Process?

Assessment

An older adult has type 1 diabetes. He can perform self-care activities but needs help with shopping and meal preparation as well as with blood glucose monitoring and insulin administration. Which type of healthcare facility would be most appropriate for him?

Assisted living facility

The surgeon enters a computerized order for a patient in the postoperative period after a unilateral thoracotomy for lung cancer. The order states: OOB in AM. Which action indicates that the nurse is following the surgeon's order? The nurse:

Assists the patient out of bed

The nurse is seeing a patient at home with a new colostomy. In formulating the plan of care, what is the priority long-term goal for this patient? The patient will:

Assume self-care in colostomy management

How does cognitive behavior therapy help with pain?

Attempts to alter negative thought patterns.

The nurse obtains a blood pressure reading of 160/90 from a cardiac patient. What is the first action by the nurse?

Check the patient's pattern of blood pressures over the past 3 days.

The nurse is teaching a client who sustained an ankle injury about cold application. Which instruction should the nurse include in the teaching plan?

Check the skin frequently for extreme redness.

A nurse who has been practicing for 3 years in an acute care facility is caring for a post-hip surgery patient. The nurse observes an abnormal change in vital signs and associates these changes with a postoperative bleeding problem. The nurse is demonstrating which proficiency level?

Competent

A 4-year-old child is brought to the emergency department by his mother. He has a large bruise on his left chest and multiple contusions on his face. His mother tells you her boyfriend intentionally pushed the child down the stairs in anger. The child appears to be in a great deal of pain. Which of the following four correct items should the nurse do first?

Complete a physical assessment of the child.

A client comes to the outpatient center for preoperative testing one week prior to the elective procedure. When is the best time to perform perioperative teaching?

During the preoperative appointment

Which describes the ethical concept of fidelity?

Duty to keep promises

When should the nurse make systematic observations about a patient?

Each time the nurse interacts with the patient

A nurse visits a high school to give a presentation on HIV prevention. In what role is this nursing acting?

Educator

The nurse is caring for a client who is in labor and who is reporting a lot of pain. Which type of cutaneous pain management may be most beneficial for this client?

Effleurage

The primary purpose of communication is to

Exchange information

After sustaining injuries in a motor vehicle accident, a patient experiences a decrease in blood pressure and an increase in heart rate and respiratory rate despite surgical intervention and fluid resuscitation. Which stage of the general adaptation syndrome is the patient most likely experiencing?

Exhaustion

The nurse is participating in a family conference regarding one of the patients on the geriatric unit. During the conference, each family member is asked about his role in the family, communication style, coping strategies, and relationship with other family members. This type of family conference best illustrates the use of which theory related to family care?

Family interactional theory

Which one of the following clients would probably have a higher than normal respiratory rate? A client who has:

Had surgery and lost a unit of blood intraoperatively

Why might skin integrity and wound healing be compromised in the client who takes blood pressure medications? Antihypertensives:

Increase the risk of ischemia

A patient develops localized heat and erythema over an area on the lower leg. These findings are indicative of which secondary defense against infection?

Inflammation

The nurse reviews the patient's laboratory results. What component of informatics is the nurse viewing?

Information

Which portion of the ear is responsible for maintaining equilibrium?

Inner ear

community health nurse gathers information about how individuals in a low-income neighborhood perceive the community and its state of health. Which of the following assessment strategies would be appropriate?

Interviewing residents living on every fifth block

An 18-year-old client is brought to the emergency department following a motorcycle accident. The client has lost a large volume of blood and nurses are unable to establish IV access using a peripheral vein. His or her blood pressure is barely palpable. Which is the best IV route for immediate fluid resuscitation?

Intraosseous catheter

The Code of Ethics for Nurses:

Is not legally binding

The patient is struggling with a decision whether or not to receive experimental treatment. What is the nurse's role when caring for this patient?

Listen to the patient's thoughts, ask questions, and provide support.

CINAHL is a(n):

Literature database

Which body organ is mostly responsible for the metabolism of medications?

Liver

The nurse notes a small pulsation at the fifth intercostal space midclavicular line. This should be documented as a:

Normal finding

The nurse believes that abortion is murder of the unborn child. While at work, the nurse is assigned a woman with septicemia following an abortion. Which concept most specifically requires the nurse to provide high-quality care for this patient?

Nursing ethics

The nurse administering pain medication every 4 hours is an example of which aspect of patient care?

Nursing intervention

A nurse is caring for a 25-year-old male quadriplegic patient. Which of the following treatments would the nurse perform to decrease the risk of joint contracture and promote joint mobility?

Passive ROM

On a patient's admission to the hospital, a nurse asks the patient whether he has a living will or durable power of attorney for healthcare. He states he does and provides a copy for the chart. The basis for the nurse's inquiry is which of the following?

Patient Self-Determination Act (PSDA)

The nursing assistive personnel (NAP) informs the nurse that a patient has fallen out of bed and is in pain. The nurse assesses the patient and provides care. Identify the correct documentation of the fall.

Patient found on floor by NAP Smith and verbalizing (L) hip pain.

Joe is constipated and asking for a snack. The nurse offers an apple or orange.

Promotes

Which nutritional goal is appropriate for a patient newly diagnosed with hypertension? The patient will:

Restrict his use of sodium

Which of the following statements regarding palliative sedation is true?

The Hospice and Palliative Nurses Association promotes palliative sedation to manage unendurable and refractory symptoms.

A client is admitted to a long-term care facility. The nurse knows that federal law requires the use of:

The Minimum Data Set (MDS) for assessment

Which describes perception?

The ability to interpret impulses transmitted from the receptors that give meaning to the stimuli

Which of the following is an example of data that should be validated?

The client states she eats a low-sodium diet; she reports eating processed food.

The nurse uses his hands to direct energy fields surrounding the patient's body. After this intervention, the patient states that his pain has lessened. How should the nurse document the intervention?

Therapeutic touch was performed; patient verbalized lessening of pain after treatment.

Of the following recommended interviewing techniques, which one is the most basic? (That is, without the intervention, the others will all be less effective.)

Using active listening

The nurse manager performs a risk-benefit analysis to determine the minimum number of staff the unit will need over the Christmas and New Year's holiday to allow as many nurses to take time off as possible while maintaining the safety of the patients. What ethical problem-solving approach is this nurse manager using?

Utilitarianism

The decision is made to withdraw life support from Emma and she is changed to "DNAR" status. What does this designation mean for the healthcare team?

if she cardiac arrests, no action will be taken.

Which is likely to happen in a person who has long-term blindness?

other senses will likely sharpen

The unit committee in the intensive care unit is designing a research study to see whether they are meeting the spiritual needs of their patients. The study will involve patient interviews after discharge. After the interview process, the staff will examine patient statements for recurring themes. The unit committee is conducting ____________________ research.

qualitative

A patient comes to the clinic complaining of a taste disturbance. Which medication that the patient is currently prescribed is most likely responsible for this disturbance?

Phenytoin, an anticonvulsant

While applying a wet-to-dry dressing, how would the nurse explain to the patient how this procedure works for promoting healing? A wet-to-dry dressing is a:

Means of debriding the wound but also removing granulation tissue from the wound

The unit manager stops you in the hallway to discuss your inability to give safe patient care. The conversation is overheard by other nurses. The manager's comments are based on false information reported to her by a patient. This is an example of:

Slander

Which of the following is the main difference between sleep and rest?

Sleep is characterized by an altered level of consciousness.

Which of the following factors has the greatest positive effect on sleep quality?

Sleeping hours in synchrony with one's circadian rhythm

Which documentation entry related to prn medication administration is complete?

6/5/14 0900 morphine 4 mg IV given in right antecubetal fossa for pain rated 8 on a 1-10 scale, J. Williams RN

A client has been hospitalized for 6 weeks. All of the following interventions are good ones, but which intervention is specifically focused on helping the patient cope with the emotional responses to prolonged hospitalization?

Designating a corner of the patient's room to display personal mementos

An experienced nurse signs up for a class on a new electronic health record system. Which of the American Nurses Association Standards of Professional Performance does this most exemplify.

Education

The enterostomal nurse is conducting a teaching session for patients with new colostomies. Today's topic is self-assessment and signs and symptoms that must be immediately reported to the surgeon. Which sign/symptom should the nurse include in this teaching?

A stoma that is pale, dusky, or black in color

A patient of Japanese heritage avoids asking for narcotics for pain relief. The nurse writes a nursing diagnosis of Pain related to reluctance to take medication secondary to cultural beliefs. If the cultural archetype is true for this particular patient, this probably means that the patient views pain as:

A virtue and a matter of family honor

Which client has the greatest need for comprehensive discharge planning?

A woman who was just diagnosed with renal failure and has started peritoneal dialysis

When teaching a client about the concept of metabolism and energy from foods, how much energy would the nurse explain is released from 45g of protein? Enter numeral only.

Answer = 180 (kcal) 45 x 4 kcal = 180 kilocalories (kcal)

How many kcal would be available if a client has just eaten a food consisting of 4 grams of protein, 18 grams of carbohydrate, and 1 gram of fat? Enter numeral only.

Answer = 97 (4x4) + (18x4) + (1x9) = 16 + 72 + 9 = 97

The quality and risk nurse in the local hospital is performing a hospital survey on sentinel events. Which of the following statements would the nurse use to best describe a sentinel event?

An unexpected event involving death or serious physical or psychological injury

Which assessment should the nurse perform if she notes a palpable thyroid gland?

Auscultate the thyroid gland for bruits.

Confidentiality will be maintained by a nurse who believes in and values the ethical principle of:

Autonomy

Anna is recovering from a thyroidectomy in which her parathyroid gland was also removed. She tells the nurse she has muscle cramping as well as numbness and tingling in her fingers and toes. The nurse assesses a positive Chvostek's sign.Which electrolyte imbalance is causing the problem?

Hypocalcemia

A client with a calcium deficiency also should be tested for a deficiency in which vitamin?

D

The nurse and other hospital personnel strive to keep the patient care area clean. This most directly illustrates the ideas of which nursing theorist?

Florence Nightingale

Which of the following is the most appropriate goal for a patient with the nursing diagnosis of Deficient Fluid Volume?

Fluid balance restored, as evidenced by moist mucous membranes and urinating every 4 hours.

A mentally competent patient has an extremely low blood count and will likely die without a blood transfusion. The patient knows the risk, but continues to refuse the blood. Which action by the nurse is the most appropriate?

Follow the patient's wishes and do not administer a blood transfusion.

Christina is on chemotherapy for breast cancer. She is experiencing tetany symptoms with tingling of the extremities. She has been started on aluminum hydroxide with meals. Which electrolyte imbalance is causing the problem?

Hyperphosphatemia

The nurse is caring for a patient in his home. After several visits and review of the plan of care, the nurse notices the patient will not follow the diet and exercise regimen. What is the most appropriate action by the nurse?

Identify why the patient is not following the plan and revise the plan in collaboration with the patient

Vulnerable populations are those most likely to develop health problems and experience poorer outcomes because of limited access to care and a wide variety of other stressors. Therefore, when caring for a patient from a vulnerable group, it is most important for the nurse to focus on:

Identifying the patient's strengths and resources

A nurse makes a nursing diagnosis of Acute Pain related to the postoperative abdominal incision. She writes a nursing order to reposition the client in a comfortable position using pillows to splint or support the painful areas. What type of nursing intervention did the nurse write?

Independent

Which form of communication is the nurse using when interviewing the patient during the admission health history and physical assessment?

Interpersonal

A patient with pitting edema in the feet and ankles has excess volume in which fluid compartment?

Interstitial

Edema is caused by an excess of which type of fluid?

Interstitial

A nurse is assessing a healthy, older adult patient for an exercise program to be offered at the local hospital. During the evaluation, the nurse notes the following vital signs: P = 72, RR = 16, BP = 132/70. After 3 minutes of moderate-intensity running on the treadmill, the patient becomes short of breath and states, "I have to stop. I can't do this anymore." The nurse measures his vital signs again: P = 152, RR = 40, BP = 172/98. She instructs him to rest. Vital signs return to baseline after 15 minutes. The nurse should recognize his symptoms as associated with which of the following?

Limited activity tolerance

The nurse caring for a patient with recurrent abdominal pain of unknown origin addresses the patient by name and puts her hand on her shoulder and offers reassuring words: "You'll be okay. Try not to think about things too much, if you can." How would you evaluate the nurse's verbal and nonverbal communication?

Message provides false reassurance

A patient develops a respiratory rate 6 breaths/min after receiving IV hydromorphone (Dilaudid) 2.0 mg. Which medication should the nurse anticipate administering to this patient after notifying the prescriber of this side effect?

Naloxone (Narcan)

A patient develops a respiratory rate of 6 breaths/minute after receiving the opioid hydromorphone. Which medication should the nurse anticipate administering to this patient after notifying the prescriber of this side effect?

Naloxone (Narcan)

Over the next few days, Mr. Martin's infection gets worse and he is sleeping most of the time. The nurse must place an artificial airway to suction the secretions from his lungs. Which type of artificial airway would work best?

Nasopharyngeal airway

The nurse assesses a 4-year-old child's vision as 20/40. This finding is considered:

Normal

To assure effectiveness, when should the nurse stop rubbing antiseptic hand solution over all surfaces of the hands?

Once fingers and hands feel dry

The nurse manager is devising a teaching schedule for the staff who are about to begin using a new type of patient bed in the ICU. Implementation is planned in 6 weeks. When is the best time for the manager to schedule the teaching sessions?

One week before implementation

The nurse is looking for the most current evidence related to safe medication administration. What source provides the most reliable information?

Online drug formulary

The nurse is caring for a patient who emigrated from Puerto Rico. She can best care for this patient by learning about the:

Patient's individual cultural beliefs

A patient who sustained rib fractures in a motor vehicle accident is stating that his pain medication is ineffective. Inadequate pain control places this patient at risk for which complication?

Pneumonia

Chest percussion and postural drainage would be an appropriate intervention for which conditions? Select all that apply.

Pneumonia

The nurse is performing a sleep assessment and suspects a patient is experiencing sleep apnea. What will be implemented next to confirm the diagnosis?

Polysomnography

The intraoperative nurse observes the anesthesiologist administer general anesthesia, insert the endotracheal tube, and take control of the airway. The nurse understands that the next important nursing intervention for this patient is to:

Position the patient

Which electrolyte is the primary regulator of fluid volume?

Sodium

Which intervention by the nurse is most appropriate when she notices that her dying patient has developed a "death rattle"?

Turn the patient on his side and raise the head of the bed.

Which informatics concept concerns the appropriate use of knowledge in managing or solving human problems?

Wisdom

Which nursing action can manage unpleasant olfactory stimuli?

Emptying commodes and bedpans immediately

Surgeries are commonly classified by which of the following? Select all that apply.

- Acuity - Level of urgency

A client is admitted to the birthing unit to rule out preterm labor. The nurse charts only abnormal findings. This type of charting is a form of:

Charting by exception

Which technique is best for teaching a nursing assistant how to perform finger-stick glucose testing?

Demonstrate the procedure; then ask for a return demonstration.

A client's daughter tells the nurse that she wants to be with her mother when she dies. The client's respiration is irregular and her lungs are congested. The daughter tells the nurse that she would like to go home to change her clothes, but that she is afraid her mother might die before she returns. What is the nurse's best response?

"Your mother could live for days or a few hours; you should do whatever you are comfortable with."

The nurse is administering morning medications including a once-a-day aspirin to a client with cardiovascular disease and diabetes mellitus. The client asks the nurse why the health-care provider prescribed an aspirin when he or she has no pain. What is the nurse's best response?

"Your risk for heart attacks and strokes can be decreased by taking aspirin every day."

The nurse is conducting a risk appraisal related to the patient's lifestyle choices. What questions would be appropriate for the nurse to ask? Select all that apply.

- "What is your job?" - "What is your marital status?" - "What are your hobbies?" - "Are you sexually active?"

A nurse is suctioning a male client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of:

- 15 seconds

The nurse is teaching a client how to use a portable blood pressure device to monitor his blood pressure at home. It would be most important for the nurse to:

Ask the client to demonstrate the use of the blood pressure device

The nurse is caring for a patient with a Salem sump double lumen nasogastric (NG) tube to suction. The patient complains of nausea and has mild abdominal distention. What is the nurse's priority action?

Check placement of the NG tube.

The nurse must administer an enema to an adult patient with constipation. Which of the following would be a safe and effective distance for the nurse to insert the tubing into the patient's rectum? Select all that apply.

- 3 in. (7.6 cm) - 4 in. (10.2 cm)

Which objective measures can a nurse use to assess a person's dietary history. Select all that apply.

- 3-day food record diary - Food questionnaire - 24-hour memory recall

Throughout the course of his illness, a patient has denied its seriousness, even though his health professionals have explained prognosis of death very clearly. Physiological signs now indicate that he will probably die within a short period of time, but he is still firmly in a state of emotional denial. The patient says to the nurse, "Tell my wife to stop hovering and go home. I'm going to be fine." How should the nurse respond?

"You seem very sure that you are not going to die. Please tell me more about what you are feeling."

Which of the following clients would most likely require home health services? Select all that apply.

- 32-year-old terminally ill woman with a supportive family - 92-year-old man living independently with multiple medical problems

Which hormones are responsible for working on the kidneys to regulate fluid balance? Select all that apply.

- Antidiuretic hormone (ADH) - Renin-angiotensin system (RAAS) - Aldosterone

Which urine specific gravity would be expected in a patient admitted with dehydration?

1.030

Why is the information obtained from a swab culture of a wound limited?

A positive culture does not necessarily indicate infection because chronic wounds are often colonized with bacteria.

A nurse working in a rehabilitation facility has a physician's prescription to contact other therapists as required by patient need. A patient has started to have difficulty with bathing and grooming. Which therapist should the nurse contact to assist the patient to regain these skills?

Occupational therapist

After undergoing dural puncture while receiving epidural pain medication, a patient reports a headache. Which action can help alleviate the patient's pain?

Offer caffeinated beverages to constrict blood vessels in his head.

The Joint Commission requires which type of assessment to be performed on all patients?

Pain

A postoperative client has been placed on a clear liquid diet. Which item should the nurse offer the client?

Popsicle

Which is the greatest determinant of intracellular osmolality?

Potassium

Which assessment finding is considered an age-related change?

Presbycusis

When counseling a patient about behaviors to reduce stress, which of the following goals should the nurse put on the care plan?

"The patient will limit his intake sweet and salty foods."

Which are examples of chemoreceptors?

Taste buds

Which of the following is an example of a problem that nurses can treat independently?

Nausea

According to Erikson, a behavior demonstrating an important psychosocial task for a toddler would be for the child to:

Act defiantly by refusing to hold the mother's hand while crossing the street

Adrianne is in labor. She is moaning and crying out during contractions. Which nonverbal response is being demonstrated?

Behavioral pain response

What database would the nurse use to restrict the search to nursing articles only?

CINAHL

To achieve balance, body mass must be distributed around which point?

Center of gravity

In the emergency department (ED), the patient is diagnosed with a dislocated humerus. What type of anesthesia would the nurse anticipate will be used to repair the dislocation in the ED?

Conscious sedation

In which capacity would a clinical nurse specialist best serve a health-care facility?

Educating clients and families on disease management.

What should be evaluated when assessing for type of cough? Select all that apply.

- Dry, productive, or hacking - When does it occur - How long has client had cough - What makes it worse or better

The nurse is caring for a client whose intravenous infusion ran in quickly over a short amount of time, placing the client in fluid overload. What symptoms should the nurse anticipate? Select all that apply.

- Elevated blood pressure - Increased pulse strength - Increased pulse rate

What type of loss is most common among patients who are hospitalized for complex health conditions?

Dignity

What is a common characteristic of aging skin?

Diminished sweat gland activity

The nurse is caring for a client after a large abdominal surgery. He is restless and uncomfortable. Which positioning change could be most beneficial? Select all that apply.

- Head elevation - side-lying

Homelessness is a growing problem in the United States. What are the primary causes of homelessness? Select all that apply.

- Lack of job skills - Lack of social skills - Underlying mental illness - Substance abuse

The nurse is preparing to administer ophthalmic eye drops to her patient. What are the most appropriate actions for administering eye drops? Select all that apply.

- Place the patient in a high-Fowler's position. - Administer the eye drops from the inner to the outer canthus of the eye. - Apply the medication into the conjunctival sac.

The nurse is caring for a patient in the late stage of Alzheimer's disease who is noncommunicative. The nurse suspects the patient is experiencing pain based on what assessment findings? Select all that apply.

- Rapid blinking - Labored breathing - Restlessness

A nurse is preparing to perform a focused assessment of a client's respiratory system. Which aspects should the nurse include in the assessment? Select all that apply.

- Rate - Body position - Breath sounds - Use of accessory muscles

What are some strategies a new nurse can use to develop skills in achieving cultural competence? Select all that apply.

- Read the literature and study nursing theories and principles pertaining to culture - Take advantage of as many opportunities as possible to interact with persons from diverse cultures

The client with severe pain is nauseated and vomiting. Which routes could be considered for administration of an opioid medication? Select all that apply.

- Rectal - Nasal - Subcutaneous - Intravenous - Transdermal

An 85-year-old patient is admitted through the emergency department for confusion and disorientation. The family states, "We don't know what is wrong. He has been fine at home. This confusion just started 2 days ago and seems like it is getting worse." What is the most appropriate first response for the nurse to make?

"Can you tell me about his home medications and other illnesses he has?"

sources of complex carbohydrates

- Potatoes - Spaghetti - Beans - Wheat bread - Corn

Which of the following regarding nursing diagnosis are accurate? Select all that apply.

- Provide the basis for nursing interventions - Are validated with patient and family when possible

Which of the following populations are considered high risk for sensory deprivation? Select all that apply

- The homebound - Those in prison - Those who are depressed

In which position would the nurse place the client to perform percussion and postural drainage for the middle lung lobes?

- Trendelenburg

The nurse is assessing vital signs for a client after a surgical procedure on the left leg. IV fluids are infusing. It would be most important for the nurse to:

Compare the left pedal pulse with the right pedal pulse

Gas exchange that occurs in the alveoli-capillary membrane is referred to as what type of respiration?

External respiration

Is a federal insurance program designed to fund healthcare for people aged 65 years and older, the disabled, and those with end-stage renal disease.

Medicare

What intervention might the nurse suggest to the patient to promote rest?

Meditate for 30 to 60 minutes in the evening.

The nurse is encouraging a client to cough and deep breathe as well as use the incentive spirometer. She also performs chest physiotherapy twice a day. What is the purpose of these interventions?

Mobilize secretions

After inserting a nasogastric tube, what would be the nurse's priority action prior to starting the first tube feeding?

Obtain radiographic verification (x-ray).

The nurse is caring for a client with asthma and pneumonia who is hyperventilating. Which acid-base imbalance would be anticipated?

Respiratory alkalosis

A patient underwent abdominal surgery for a ruptured appendix. The surgeon did not surgically close the wound. The wound healing process described in this situation is:

Secondary intention healing

While receiving nutrition through a gastric tube, the client complains of feeling full and nauseated. What should the nurse do at this point?

Stop the feeding, assess the client, flush the tube, wait an hour, then measure gastric contents and restart the feeding at a slower rate

The nurse assesses that her patient's intravenous solution has infiltrated into the tissues. What action should she take first?

Stop the infusion immediately.

Which would be an appropriate topic for the elementary school nurse to include in health promotion activities for students?

Stranger danger

The nurse educates a patient about the primary risk factors for irritable bowel syndrome. Which behavior by the patient would be evidence of learning? The patient:

Takes measures to reduce her stress level

The patient experiences extensive third-degree burns. What type of healing does the nurse expect? Healing by:

Tertiary intention

A nurse has sound, scientific evidence to support changing a procedure that would reduce catheter-related infections on the unit. The unit manager states, nevertheless, that she is unwilling to make the change because it would too costly. Which response by the nurse represents assertive communication?

"I'd like to help gather information regarding cost of new materials versus the savings in treating infections."

A client who has been hospitalized for an infection states, "The nursing assistant told me my vital signs are all within normal limits; that means I'm cured." The nurse's best response would be which of the following?

"Your vital signs are stable, but there are other things to assess."

The nurse is assessing a patient who is complaining of chest pain, clutching his chest, and is short of breath. Which assessment question would be appropriate for the nurse to ask?

- "Does the pain radiate to your arm, jaw, or shoulder?"

The nurse is speaking with a group of nursing students about the use of heat and ice for pain control. Which situations are best for this modality? Select all that apply.

- Activity-induced muscle pain - Low back pain with spasticity - Pain from obstetric procedures

A registered nurse (RN) is developing a plan of care for a client admitted with pneumonia. Which tasks can the RN delegate to the nursing assistive personnel (NAP)? Select all that apply.

- Bathing the client - Shaving the client - Providing oral care - Administering lubricating eye drops - Performing a sterile dressing change

The nurse on the pediatric unit is preparing a teaching plan related to children and drowning. Which of the following sources of drowning will the nurse include in her plan? Select all that apply.

- Bathtub - Child wading pool - Toilet - Mop bucket filled with water

Which of the following tasks may be delegated to a CNA or NAP? Select all that apply.

- Collecting and testing a stool sample for occult blood - Assisting with placing a fracture pan on an immobile patient

Treatments for urinary incontinence

- Devices - Timed voiding - Surgical treatments - Medications - Sacral nerve stimulation - Kegel exercises

The nurse administers an antitussive/expectorant cough preparation to a patient with bronchitis. Which of the following responses indicates to the nurse that the medication is effective?

- Dry, unproductive cough is reduced, but her voluntary coughing is more productive.

The pediatric nurse educator is teaching a group of parents about distinguishing between food allergies and food intolerance. The nurse should teach parents that which of the following is/are considered to be true food allergens? Select all that apply.

- Egg whites - Shellfish - Peanuts

Goals for Healthy People 2020 include which of the following? Select all that apply.

- Eliminate health disparities among various groups. - Increase the quality and years of healthy life.

Of the following interventions, which is/are likely to reduce the risk of postoperative atelectasis? Select all that apply.

- Encourage coughing and deep breathing. - Administer pain medication.

Which diagnostic tests provide direct visualization of the intestinal tract? Select all that apply.

- Fiberoptic colonoscopy - Esophagastroduodenoscopy

The mother of a 3-month-old infant comes to emergency department and states, "My baby has been having severe diarrhea for 4 days. She is crying all the time." In formulating the plan of care to moderate the diarrhea, the nurse focuses her intervention(s) on which of the following? Select all that apply.

- Fluid management - Electrolyte balance - Skin integrity

Which are included as part of the USDA dietary guidelines? Select all that apply.

- Food safety - Adequate exercise - Choosing a nutritious diet

The community health nurse is preparing a teaching plan on food choices that promote normal bowel elimination. Which of the following foods should the nurse teach patients to be sure to include in their diet? Select all that apply.

- Fresh fruits - Whole-grain cereals

or a patient with hearing loss, it is essential to minimize the risk of further damage to the auditory nerve. Which of the following medications may need to be discontinued if the patient is taking them? Select all that apply.

- Furosemide, a diuretic - Aspirin, an analgesic

Which tasks will the nurse perform when preparing the client's body for the morgue? Select all that apply.

- Gently pressing on the eyelids to close the eyes. - Padding wrists with gauze and tying the wrists together - Wrapping the body in a shroud or placing it in a body bag.

The community health nurse is preparing a teaching plan for emergency preparedness in the instance of a major disease outbreak. Which of the following will the nurse include in the plan for the home setting? Select all that apply.

- Have nonprescription drugs available. - Store a 2-week supply of bottled water. - Obtain an annual influenza vaccination.

Identify interventions that would be effective when assisting a client in making behavior changes that would reduce his health risk factors. Select all that apply.

- Have the client identify two or three goals for change. - Help the client to understand the benefits of change. - Allow the client to identify available support and resources within the community.

The nurse is working with a group of clients in a grief support group for people who have lost spouses in the past 3 months. The nurse notices each person is in a different phase of grieving. Which factors can impede a person's response to loss? Select all that apply.

- Having had a fight with the spouse before he or she died. - Having lost a spouse with whom he or she had a close relationship. - Having had other family members pass away within the past 2 years. - Having few people to assist during the time of loss.

Which are primary purposes of nursing care? Select all that apply.

- Health promotion - Illness prevention - End-of-life care

The nurse assigned to an oncology unit reports that three of the patients with cancer do not have an appetite and have eaten little during the shift. What strategies can the nurse on the next shift use to increase her patients' appetites? Select all that apply.

- Offer frequent, smaller meals. - Keep the patients' rooms neat and clean. - Provide or assist with frequent oral hygiene.

Which part of the ECG complex represents the SA node firing and conducting the impulse through the atria?

- P wave

For which patient might the nurse use the nursing diagnosis of Risk for Ineffective Renal Tissue Perfusion?

- Patient with hypertension who is noncompliant with medication administration

The nurse receives the arterial blood gas values for a client with pneumonia. Which finding by the nurse requires health-care provider intervention?

- Pco2 level 65 mm Hg

The nurse learns in report that the assigned patient has a stage III pressure ulcer. What type of tissue does the nurse expect to find in the wound? Select all that apply.

- Subcutaneous - Dermis - Fascia

In performing a handoff report, the nurse should communicate information on which of the following? Select all that apply.

- Teaching performed - Any change in client status - Treatments administered

Knowing that discharge summary information is integral to the client's ongoing care, which of the point(s) regarding discharge summaries must the nurse be aware? Select all that apply.

- The discharge summary is important because many clients require follow-up care. - A complete discharge summary is a guide for healthcare professionals in the community. - The discharge summary is the final note in the client's health record

For which patient could the nurse collect a sputum specimen without using a suction catheter?

- The patient admitted with chronic bronchitis

The heart is regulated by the autonomic nervous system (ANS) and control centers in the brainstem. Where do the parasympathetic fibers innervate the heart?

- The vagus nerve

Which chronic diseases or conditions can have a direct impact on nutritional needs? Select all that apply.

- Traumatic injury - Alcoholism - Cognitive function

Alcohol-based solutions for hand hygiene can be used to combat which types of organisms? Select all that apply.

- Viruses - Yeasts - Molds

The nurse is talking with family members of a client who has been diagnosed with terminal cancer. Which physiological changes should the nurse tell the family to expect in the client 1 to 2 weeks prior to death? Select all that apply.

- Yellowish skin color - Increased perspiration - Nonproductive cough

Although the dying process is unique to each person, there are similar phases and experiences that people go through. List in order these phases of the active dying stage of a person dying of a serious illness.

1. Withdrawal from others 2. Decreased circulatory function 3. Increased energy and mental awareness 4. Diminished respirations and changes in breathing pattern 5. Death

At 1000 on 11/14/16, the nurse takes a telephone prescription for "metoprolol 5 mg intravenously now." What is the latest date and time the nurse will expect the prescriber to countersign the order?

11/15/16 at 1000

An adult patient is fully able to detect and respond to pain and discomfort. He has no incontinence or mobility limitations. He is of normal weight and consumes a nutritious diet. The patient has no problem with rubbing, friction, or shear. What is the Braden score for this patient?

23

As the nurse is placing the oxygen, she reflects on the percentage of oxygen being delivered via nasal cannula (NC) at 2 L. What would be the correct amount?

28%

The nurse administers acetaminophen 325 mg and codeine 30 mg orally to a patient reporting a severe headache. When should the nurse reassess the patient's pain?

60 minutes after administration

How does a risk nursing diagnosis differ from a possible nursing diagnosis?

A possible diagnosis is based on partial (or incomplete) data.

Which patient is at most risk for experiencing difficult grieving?

A young adult with three small children whose wife died suddenly in an accident

Which nursing diagnosis is most appropriate for the patient who returns from the postanesthesia care unit after undergoing right hemicolectomy surgery for colon cancer?

Acute Pain (abdominal) secondary to surgery for colon cancer

The patient with a colostomy has been incorrectly applying his ostomy appliance. The continuous contact with liquid stool has caused a skin wound around the ostomy. The nurse assesses bleeding and purulent drainage that has extended into the dermis. How will the nurse classify and document this contaminated wound?

Acute, full-thickness, open

When teaching a client about the concept of metabolism and energy from foods, how much energy would the nurse explain is released from 21 g of lipids? Enter numeral only.

Ans: 189 21 x 9 kcal = 189 kilocalories

How many kilocalories (energy) are released from metabolism of 28 g of carbohydrates? Enter numeral only.

Answer = 112 28 x 4 kcal = 112 kcal

Laboratory test results indicate that warfarin anticoagulant therapy is suddenly ineffective in a patient who has been taking the drug for an extended period of time. The nurse suspects an interaction with herbal medications. What type of interaction does she suspect?

Antagonistic drug interaction

Judy has cared for her debilitated husband for several years. After his peaceful death under hospice care, she remarries within 6 weeks of his passing. What type of grief may she have experienced?

Anticipatory grief

A patient with a history of mitral valve replacement, hypertension, and type 2 diabetes mellitus undergoes emergency surgery to remove an embolus in her right leg. Which factor contraindicates the use of epidural analgesia in this patient?

Anticoagulant therapy

A client presents to the emergency room with vomiting and diarrhea. The client is dehydrated. Which hormone does the nurse expect to be secreted by the posterior pituitary gland to reduce water loss?

Antidiuretic hormone (ADH)

Fred just found out his wife was killed in a car accident. He visits his priest and says, "I told God that I would go to church every day for the rest of my life if He would just bring my wife back." What stage of dying and grief is Fred experiencing?

Bargaining

The nurse is admitting a patient with heart disease to the cardiac unit. When answering questions related to his health history, the patient's responses are lengthy and time consuming. What is the most important action by the nurse?

Be attentive, focus on what the patient has to say, and respond accordingly

Which of the following is most reflective of a life change for managing chronic illness?

Beginning self-injection of insulin for diabetes

An adolescent is talking to a nurse about the loss of his or her parent. Which adolescent behavior indicates a need for intervention?

Begins to cut his or her arms or legs.

Which statement best describes the procedure used to assess capillary refill?

Briefly press the tip of the nail with firm, steady pressure, then release and observe for changes in color.

The nurse is invited to a childcare center for a safety class. An employee comes running into the class and says to the nurse, "I think one of the children swallowed a poisonous chemical from our storage area." What is the first action by the nurse?

Call 911 immediately, even if the child has no symptoms.

The nurse is working with a wife who is caring for her chronically ill husband who requires around-the-clock care. The nurse notices that the wife often speaks to her husband sharply. The bed linens are soiled with food and the patient has a strong body odor. Both the house and the wife are unkempt. When encouraged to talk, the wife says, "I just drag around. I can't make myself do anything. I'm so tired of it all." What nursing diagnosis best fits these defining characteristics?

Caregiver Role Strain

Which metabolic process breaks larger particles into smaller ones and releases energy?

Catabolism

Which of the following is a client outcome criterion?

Client will sit out of bed in the chair for 20 minutes three times per day.

A mother of a school-age child seeks healthcare because her child has had diarrhea after being ill with a viral infection. The patient states that after vomiting for 24 hours, his appetite has returned. Which recommendation should the nurse make to this mother?

Consume a diet consisting of bananas, white rice, applesauce, and toast.

A patient with a skin infection is prescribed cephalexin (an antibiotic) 500 mg orally q 12 hours. The patient complains that the last time he took this medication, he had frequent episodes of loose stools. Which recommendation should the nurse make to the patient?

Consume yogurt daily while taking the antibiotic.

When assessing a postoperative client, the nurse notices a hard, cord-like lump on the right calf that is tender to the touch. The client says that it is aching and painful. What should be the nurse's next action?

Contact the healthcare provider.

The nurse reviews the patient chart and sees a physician prescription for a new medication. The nurse is able to clearly read the medication name but the dose is not legible. What is the best action by the nurse?

Contact the physician for clarification.

Which intervention should the nurse include in the plan of care to prevent atelectasis in a client with postoperative pain from abdominal surgery?

Control pain

The nurse palpates a radial pulse on her 80-year-old patient and notes that it feels irregular. What is the most appropriate method to count this patient's pulse?

Count for 1 full minute.

Which of the following procedure techniques has the most effect on the accuracy of an apical pulse count?

Counting the rate for 1 full minute

A hospital uses a source-oriented medical record. What is a major disadvantage of this charting system?

Data may be fragmented and scattered throughout the chart.

A patient admitted to the hospital with pneumonia has been receiving antibiotics for 2 days. His condition has stabilized, and his temperature has returned to normal. Which stage of infection is the patient most likely experiencing?

Decline

The nurse on a medical-surgical unit palpates a patient's carotid pulse for 30 seconds and obtains a rate of 80 beats/min. The nurse knows in obtaining a patient's carotid pulse she must be careful that her technique does not cause a/an:

Decrease in heart rate

How are standardized (model) care plans similar to unit standards of care? Standardized (model) care plans:

Describe the care needed by patients in defined situations

An 18-year-old female has just been accepted to nursing school in another state. She says to her parents, "I know I am going away to college, but I am nervous about going." What type of stressor is this student most likely experiencing?

Developmental

The parents of three children, aged 3, 6, and 8 years, comment that although the children are close in age, they each seem to have different needs. The nurse teaches the parents what tasks the children should accomplish based on the different age groups and provide strategies to help meet the children's needs. Which theory best explains the nurse's teaching plan?

Developmental theory

The nurse is preparing to conduct a literature search to find evidence related to care of a patient with diabetes experiencing neuropathy. Which of the following keywords would the nurse use to best identify the information searched for?

Diabetic neuropathy

Which of the following is the most important reason to develop a definition of nursing?

Differentiate nursing activities from those of other health professionals

The nurse reviews a nursing order for a patient who is 4 days post-operative after hip surgery. It reads: Assist patient in bathing each morning. The nurse assesses the patient and notes that the patient is independent in bathing. What should the nurse do next?

Discontinue the nursing order on the plan of care

The nurse has just administered a subcutaneous insulin injection to her diabetic patient. What is the next immediate action by the nurse?

Dispose of the needle/syringe uncapped into a disposable sharps container.

A client's record includes an order written by a physician to not initiate resuscitative efforts in the event of a cardiopulmonary arrest. The nurse recognizes this order as which?

Do not resuscitate (DNR)

When changing a diaper, the nurse observes that a 2-day-old infant has passed a green-black, tarry stool. What should the nurse do?

Do nothing; this is normal.

It is a busy day on the medical-surgical floor, and the nurse must teach a patient ready for discharge about his medications. How can the nurse most efficiently use her time and provide this education?

Educate the patient about his medications as each one is given.

Which regulation requires health-care facilities to provide emergency care to clients who seek health care regardless of ability to pay?

Emergency Medical Treatment and Active Labor Act

Which nursing intervention should be included in the plan of care for a patient dying of cancer?

Encourage family members to participate in care of the patient when possible.

The nurse suspects a 3-year-old child who is coughing vigorously has aspirated a small object. Which action should the nurse take first?

Encourage the child to continue coughing.

The nurse is caring for a client with osteomyelitis who is diagnosed with hearing loss related to long-term medication use. Which medication may have caused this sensory loss?

Gentamicin (Garamycin)

An adult admitted to the hospital after a stroke does not respond to verbal stimuli. What should the nurse do next to try to provoke a response?

Gently shake the patient's shoulder.

The nurse is removing personal protective equipment (PPE). Which item should be removed first?

Gloves

A client informs the nurse that he has quit smoking because his father died of lung cancer 3 months ago. Based on his motivation, smoking cessation should be recognized as an example of which of the following?

Health protection

A 16-year-old male tells the nurse that he is not in the mood to do anything with his friends. He states, "For weeks now I am just not interested in doing anything and I've stopped all my sports activities. I just feel sad all the time and I just don't want to go on." The nurse completes her assessment and begins her plan of care. What is the most appropriate nursing intervention at this time?

Inform the patient you are completing a mental health referral

Computers are important for evidence-based practice because:

Information can be accessed and managed more efficiently

Your patient has multiple open wounds that require treatment. When performing dressing changes, you should:

Irrigate wounds from least contaminated to most contaminated

A hospice nurse observes a widower drinking heavily after the loss of a spouse. Which type of grief is this person experiencing?

Masked grief

How is NOC different from the Omaha System?

NOC can be used in all specialty and practice areas.

Which of the following patients with inadequate or poor quality of sleep would be the best choice for a nursing diagnosis of Disturbed Sleep Patterns?

New mother of twins

The client's arterial blood gases are pH 7.36; PCO2 37; HCO3- 24. How would the nurse describe these gases?

Normal

What is typically the most reliable indicator of pain?

Patient's self-report

Which condition in older men can result in impaired flow of urine from the bladder into the urethra?

Prostatic hypertrophy

What is the function of the stratum corneum?

Protects the body against the entry of pathogens

The nurse is caring for a patient admitted with a closed head injury. Which action by the nurse is appropriate when providing hygiene for this patient?

Provide care in short intervals.

Why is Fowler's or semi-Fowler's the appropriate position when teaching a patient to cough and deep-breathe?

Provide optimal lung expansion

Which task can the nurse safely delegate to the nursing assistive personnel?

Providing indwelling urinary catheter care

What is the type of nursing with a focus on the community as a whole and the health status of individuals as an aggregate?

Public health nursing

The nurse must administer ear drops to an infant. How should she proceed?

Pull the pinna down and back before instilling the drops.

A person who is deprived of REM sleep for several nights in succession will usually experience:

REM rebound

How should the nurse classify pain that a patient with lung cancer is experiencing?

Radiating

The nurse conducting a pain assessment for a patient would recognize deep somatic pain as which of the following?

Radiating

Which of the following helps the body release growth hormone (growth hormone assists in tissue regeneration, synthesis of bone, and formation of red blood cells)?

Restful sleep

A preschool-age child is scheduled for a tonsillectomy. Which strategy might help lessen the child's anxiety before surgery?

Show the child a short, animated video (DVD) about the hospital visit and procedure.

The nurse is caring for a patient newly diagnosed with diabetes. The patient tells the nurse, "After searching the Internet, I found out that I don't need insulin. All I need to do to control blood sugar is drink a mixture of vinegar and apple juice." What teaching should the nurse provide?

Show the patient how to choose reputable, trustworthy healthcare Web sites.

A 36-year-old mother of three small children has had nausea, vomiting, and extreme fatigue for the past 2 days. She calls her mother and tells her she is ill and asks whether her mother can care for the children. Which stage of illness behavior is she experiencing? Choose all that apply.

Sick-role behavior

The nurse has been teaching a student how to perform mouth care for her unconscious patient. The student will show evidence of learning if she places the patient in which position for this care?

Side-lying

A mother has brought her 8-month-old daughter to the healthcare clinic for a well-child appointment and any needed immunizations. To assess the child's physical development with age-appropriate norms, which of the following questions should the nurse ask? Is your child able to:

Sit up without support?

The nurse has been explaining advance directives to a patient. Which response by the patient would indicate that he has correctly understood the information? "An advance directive is a document that:

Specifies your healthcare instructions should you become unable to make self-directed decisions"

The mother of a preschool child dies suddenly of a ruptured cerebral aneurysm. What recommendation should the nurse make to the family regarding how to most therapeutically care for the child?

Spend as much time as possible with the child.

A couple comes in to the obstetrician's office for a prenatal check. The woman states, "I know breastfeeding is important but I am not comfortable with this feeding method. I don't think it will work for us." The most appropriate action by the nurse is to:

Support the couple's decision

A patient is having pain and has requested a dose of analgesic medication. The medication administration record indicates that he prescribed the narcotics hydromorphone (Dilaudid) intramuscularly and morphine sulfate intravenously. Where should the nurse first assess to determine which medication to administer?

The patient's pain level

What is the primary goal that the nurse should establish for a patient with an open wound?

The wound will remain free of infection throughout the healing process.

During which of the following developmental stages does a person tend to need the most hours of sleep?

Toddler

Which stimulates an infant's tactile senses?

holding and cuddling

Mark has chronic renal failure. He missed dialysis yesterday and today he feels weak with intestinal colic. His ECG shows dysrhythmias with tall T waves. Which electrolyte imbalance is causing the problem?

hyperkalemia

The American Nurses Association (ANA) believes nurses should not participate in active euthanasia (and assisted suicide) because such acts violate ____.

the Code of Ethics for Nurse

The nurse enters a room and notes the client's eyes are closed. The nurse says the client's name without response. What should be the nurse's next action?

touch the client

Which of the following is an abnormal capillary refill finding that the nurse should report?

4 seconds

The nurse works with the respiratory therapist to administer a patient's breathing treatments. He reports the patient's breathing status and tolerance of the treatment to the primary care provider. The nurse then discusses with the patient the options for further treatment. This is an example of:

Collaboration

The nurse is preparing a patient for an invasive diagnostic test that will provide direct visualization of the rectum, entire large intestine, and distal small bowel. The nurse should teach and give the patient written instructions about which of the following tests?

Colonoscopy

How should a nurse behave in the presence of a client who is dying?

Communicate as though the client can still hear and understand everything being said.

According to general systems theory, which element is part of the supra system?

Community

Pressure ulcers are directly caused by which of the following conditions at the site?

Compromised blood flow

A community health nurse planning a new program for teen pregnancy prevention designs a community assessment covering the structure of her target. Which of the following areas would she include?

Demographic data of residents in the community

During admission to the unit, a patient states, "I'm not worried about the results of my tests. I'm sure I'll be all right." As he observes the patient, the nurse notes that the patient is shaky, tearful, and does not make eye contact. Unfortunately, the nurse is called away to an emergency before he has time to complete this discussion. Which of the following goals is most appropriate for the nurse to establish when returning to the patient? The patient will:

Discuss his concerns and fears with the nurse

The nurse just gave an immunization to Jonathan, a 2-year-old.Which pain intervention would be most beneficial?

Distraction

The nurse plays music for a child with leukemia who is experiencing pain. Which pain management technique is this nurse using?

Distraction

A patient had a CVA (stroke) 2 days ago, resulting in decreased mobility to her left side. During the assessment, the nurse discovers a stage I pressure area on the patient's left heel. What is the initial treatment for this pressure ulcer?

Elevation of the left heel off the bed

After a hip fracture, Joseph has become more sedentary. He notices an area on his right calf that is painful, warm to the touch, red, and swollen, and he shows it to the visiting nurse. What action should the nurse take?

Encourage Joseph to go to the emergency department

A client with a nursing diagnosis of Imbalanced Nutrition, Less Than Body Requirements r/t diagnosis of colon cancer and depression has no desire to eat. What is one method of assuring the client receives the needed nutrition?

Encourage family members to bring foods the client likes to eat.

When released in response to alarm, which of the following substances promotes a sense of well-being?

Endorphins

According to Erikson, which of the following must a middle-aged adult do to be prepared for the final stages of life? The adult must:

Feel she has made a contribution to society

Which occurs with the hematocrit level in the blood while IV solution is administered?

Hematocrit decreases

A patient receiving a unit of whole blood begins to complain of "feeling funny" and having chills. The nurse assesses that the patient has dyspnea, hypotension, and tachycardia. Which blood transfusion reaction should the nurse suspect?

Hemolytic

Upon further assessment, the nurse discovers that Mr. Martin has conversational dyspnea and use of accessory muscles. His sputum is dark yellow-green and thick. He is having difficulty expectorating. What is the best position for Mr. Martin?

High Fowler's

A female patient has excessive facial hair. The nurse should document this finding as:

Hirsutism

A patient has a stage II pressure ulcer on her right buttock. The ulcer is covered with dry, yellow slough that tightly adheres to the wound. What is the best treatment the nurse could recommend for treating this wound?

Hydrocolloid dressing changed as needed

Vic is in the final stages of cancer with metastatic bone disease. He is weak and constipated with anorexia, nausea, and vomiting. He is very thirsty and urinating often. Which electrolyte imbalance is causing the problem?

Hypercalcemia

The nurse examines the electrocardiogram (ECG) tracing of a client and notes tall T waves. What electrolyte imbalance should the nurse suspect?

Hyperkalemia

Keith experienced a back injury at work. The pain shoots down his left leg and he can't find a comfortable position that relieves his distress. He's tried every pain management suggestion and multiple prescription pain medications with minimal relief.

Intractable pain

Which laboratory result on a client's health record should alert the nurse to a potential problem?

K+ = 5.2 mEq/L

Which collaborative interventions will help prevent paralytic ileus in a patient who underwent right hemicolectomy for colon cancer?

Keep the patient NPO until bowel sounds return.

Which body organ is mostly responsible for medication excretion?

Kidney

A patient reports that he uses music therapy to help control his chronic pain. Music therapy works by prompting the release of endogenous opioids during which stage of the pain process?

Modulation

The nurse is caring for a client who says, "Food just doesn't taste good anymore." What priority action should the nurse take?

Monitor dietary intake.

In evaluating a client's blood pressure for hypertension, it would be most important to:

Monitor the blood pressure for a pattern

A patient is prescribed morphine sulfate 4.0 mg intravenously for postoperative pain. Which action should the nurse take before administering the medication?

Monitor the patient's respiratory status.

A patient complains of an impaired sense of smell. Which cranial nerve might have been affected?

Olfactory

Which expected outcome is best for the patient with a nursing diagnosis of Acute Pain related to movement and secondary to surgical resection of a ruptured spleen and possible inadequate analgesia?

On a scale of 0 to 10, the patient will rate pain as a 3 while in bed or as a 4 during ambulation.

The nurse providing care to the patient with a fracture explains how bones heal. Which type of cells repair damaged bone and build new bone to keep the skeleton strong?

Osteoblasts

A patient with end-stage cancer is prescribed morphine sulfate to reduce pain. For which effect is this medication prescribed?

Palliative

A 60-year-old patient with a treatable form of breast cancer has decided not to pursue radiation or chemotherapy. The nurse believes that the patient should be treated. She coerces her into receiving treatment by continuing to remind the patient about her responsibilities for raising her children. What type of behavior has the nurse displayed?

Paternalism

What nursing intervention should be applied for a client with pneumonia of the right lower lobe?

Place on left side and elevate the foot of the bed.

The nurse is beginning her routine assessment on a 3-year-old child. To gain trust and support from the child, the most appropriate action by the nurse is to:

Play a game of ball with the child

The nurse is caring for a patient with dementia who becomes agitated every evening. Which intervention by the nurse is best for calming this patient?

Playing soft, calming music during the evening

What physiological process causes the severe pain of menstrual cramps?

Prostaglandin activity

Michael experiences chronic low back pain. The pain is especially significant while bending to put on his socks and shoes.Which pain intervention would be most beneficial?

Relaxation techniques

A 6-year-old boy is admitted to the hospital for a surgical procedure associated with a hospital stay. When the nurse asks his mother about the boy's sleep patterns, she says, "Sometimes he will get out of bed, walk into the kitchen, and get the cereal out of the cabinet. Then he just turns around and goes back to bed." The nurse explains that he is sleepwalking. The best nursing diagnosis for the boy would be:

Risk for Injury related to sleepwalking

For which of the following purposes is a graphic flowsheet superior to other methods of recording data?

Seeing the patterns of a patient's fever

Which of the following is the most appropriate nursing goal for a 2-year-old who is to have a tonsillectomy?

Separation anxiety will be minimal.

Which electrolyte is responsible for maintaining serum osmolality of the vascular compartment?

Sodium

A client with a history of schizophrenia is diagnosed with a urinary tract infection. What is probably the most significant barrier this patient faces?

Stigma associated with mental illness

Which action should the nurse take first when the patient has a score of 4 on the sedation rating scale?

Stimulate the patient.

While receiving an intravenous dose of an antibiotic, levofloxacin, a patient develops severe shortness of breath, wheezing, and severe hypotension. Which action should the nurse take first?

Stop the infusion of medication.

What is the American Nurses Association's (ANA) position on assisted suicide?

The ANA prohibits nurses from participating in assisted suicide.

The nursing student has registered for a class on pharmacokinetics. Which of the following reflects the student's accurate understanding of what he can expect to focus on in this class?

The absorption, distribution, metabolism, and excretion of drugs

A 6-week-old infant is brought to the pediatrician's office for a well-baby checkup. The nurse notes a flattening of the skull. Flattening of the skull in the infant might suggest:

The baby has been lying in the same position for several hours a day

A nurse obtains a client's vital signs. The client's vital signs are normal, but the client states the pain is 8 out of 10. What should the nurse assume about the client's pain?

The client is experiencing severe pain of 8 out of 10.

An 82-year-old patient is unsteady on her feet when walking about the room. She reports feeling a little sore but has no complaints of weakness. What is the appropriate piece of equipment to use when helping her ambulate?

Transfer belt

What do initial, ongoing, and discharge planning have in common?

They are based on assessment and diagnosis.

The nurse is about to bathe a female patient who has an intravenous line, and needs to remove her gown. The nurse should:

Thread the bag and tubing through the gown sleeve, keeping the line intact.

When providing postmortem care, the nurse places dentures in the mouth and closes the eyes and mouth of the patient within 2 to 4 hours after death. Why is the timing of the action so important?

To perform these actions more easily before rigor mortis develops

The mother of a child participating in a research study that uses high-dose steroids wishes to withdraw her child from the study. Despite reassurance that adverse reactions to steroids in children are uncommon, the mother still does not change her mind. By withdrawing from the study, the mother is exercising which right? The right

To self-determination

A patient with terminal cancer requires increasing doses of an opioid pain medication to obtain relief from pain. This patient is exhibiting signs of drug:

Tolerance

The nurse is assessing a client after surgery who is dehydrated and experiencing hypotension, tachycardia, and decreased urine output. What additional assessment should the nurse perform?

Tongue and skin turgor

Which civil laws deal with wrongs done by one person to another without a contract involved?

Tort laws

A nurse is being investigated for stealing narcotics from several patients. Which federal agency can become involved in the investigation of this incident?

U.S. Drug Enforcement Agency

Which of the following describes the difference between dehiscence and evisceration?

With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site.

If a peripheral IV access attempt is unsuccessful, what action should the nurse take?

Withdraw the needle and attempt IV access using another needle and another site.

What is the best technique for obtaining a sterile urine specimen from an indwelling urinary catheter?

Withdraw urine through the port using a needleless access device.

A client is diagnosed with an intestinal infection after traveling to a developing country. The nurse should encourage the intake of which food to optimize the gut's normal flora, creating a healthier environment?

Yogurt

The nurse is teaching a client who has iron-deficiency anemia about foods that should be included in the diet. The nurse can determine that the client understands these instructions if the client chooses which of the following foods from a sample menu?

An orange with fortified cereal

Which characteristic about pain would the nurse most consider when developing a pain management plan for a patient with chronic lower back pain?

An unpleasant sensory and emotional experience association with actual or potential tissue damage, or described in terms of such damage

A nurse admits a patient to the unit after completing a comprehensive interview and physical examination. To develop a nursing diagnosis, the nurse must now:

Analyze the assessment data

Which portion of a nutritional assessment must the registered nurse complete?

Analyzing the data

After Philip gets over the initial shock of the situation, which Kübler-Ross stage of grief is he most likely to experience next?

Anger

A nurse is caring for a client who is in the dying process. He has been ill and bedridden for over a year. His wife has previously been showing signs of grief and loss, but she is now behaving in a detached manner. The nurse knows this is which type of grief reaction?

Anticipatory grief

A 70-year-old male with diabetic peripheral neuropathy reports a burning sensation in his feet. He also states, "Those pain pills make me feel funny and they don't help my pain, so I don't take them." Which of the following is likely to be most beneficial for treating this patient's neuropathic pain?

Antiepileptic drug (gabapentin)

The nurse is caring for a patient with an infected full-thickness wound with moderate drainage and no odor. What type of dressing will be most appropriate for the nurse to apply?

Antimicrobial collagen dressings

A patient complains of a vague, uneasy feeling of dread, and his heart rate is elevated. Which of the following nursing diagnoses is most appropriate for this patient?

Anxiety

An older adult patient who underwent bowel resection is recovering from surgery without complication. He ambulates in the hallway and requires little analgesia for pain. During the healthcare team's morning rounds, the surgeon informs the patient that the lesion removed was cancerous. Which factor will likely be the patient's most significant obstacle for learning?

Anxiety associated with the new diagnosis

The client has an order for the drug digitalis, which has the effect of decreasing the heart rate. Which site should the nurse use to obtain a pulse rate prior to administering the medication?

Apical

A patient with severe hemorrhoids is incontinent of liquid stool. Which of the following interventions is contraindicated?

Apply an indwelling fecal drainage device.

Which aspect of restraint use can the nurse delegate to the nursing assistive personnel?

Applying and removing the restraints

The primary care provider orders peak and trough levels for a patient who is receiving intravenous vancomycin every 12 hours. When should the nurse obtain a blood specimen to measure the trough?

Approximately 30 minutes before the next dose

A frail, elderly man is admitted to the hospital after a fall at home resulted in a left hip fracture. After surgery, he is to begin ambulating with a walker but must avoid weight bearing on his left lower leg. What is the best intervention to help him use his walker?

Arm resistance training

An older adult comes to the clinic complaining of pain in the left foot. While assessing the patient, the nurse notes smooth, shiny skin that contains no hair on the client's lower legs. Which condition does this finding suggest?

Arterial insufficiency

A physician orders an indwelling urinary catheter for a client who is mildly confused and has been combative. How should the nurse proceed?

Ask a colleague for help, because the nurse cannot safely perform the procedure alone.

At last measurement, the client's vital signs were as follows: oral temperature 98°F (36.7°C), heart rate 76 beats/min, respiratory rate 16 breaths/min, and blood pressure (BP) 118/60 mm Hg. Four hours later, the vital signs are as follows: oral temperature 103.2°F (38.5°C), heart rate 76 beats/min, respiratory rate 14 breaths/min, and blood pressure 120/66 mm Hg. Which should the nurse's first intervention be at this time?

Ask the client whether he has had a warm drink in the last 30 minutes.

A mother brings her 6-month-old infant to the clinic for a well-baby checkup. How should the nurse proceed when weighing the patient?

Ask the mother to remove the infant's clothing and diaper.

The patient shows the necessary defining characteristics, and the nurse has diagnosed Decisional Conflict related to unclear personal values and beliefs. What essential action should the nurse take to help ensure the accuracy of this diagnosis?

Ask the patient to confirm the diagnosis.

A patient tells the nurse that since taking a medication he has suffered from excessively dry mouth. Which of the following assessments would be needed to plan interventions for that symptom?

Asking the patient whether foods taste different now

While eating in the hospital cafeteria, the nurse sees a visitor display the "universal sign of choking." Her first action is to:

Assess for ineffective breathing by asking, "Are you choking?"

The nurse is developing a teaching plan on coping strategies for an extended family of a severely disabled 11-year-old child. What step should the nurse take first in developing this plan?

Assess the current coping patterns.

The certified nursing assistant (CNA) is feeding a patient and notes that the patient is having difficulty swallowing. She reports this to the primary registered nurse. What should the nurse do first?

Assess the patient and place on NPO status

To promote deep breathing, coughing, and turning by a postoperative patient on the first postoperative day, the best action by the nurse would be to:

Assess the patient's pain level before these activities

The nurse calculates urinary output for a client admitted with dehydration and determines the client's output is 800 mL/day. Which nursing intervention is most appropriate for the nurse to perform first?

Assess the urine color and clarity.

A patient had surgery 6 hours ago. When the nurse enters the room to turn him, she notes that he is restless and grimacing. Considering the patient's nonverbal communication, what action should the nurse take first?

Assess to determine the cause of the grimacing.

The nurse is helping an 82-year-old patient to ambulate in the hallway. Suddenly she states, "I feel so light-headed and weak," as her knees begin to buckle. The nurse's best action at this time would be to:

Assist the patient to slide down his leg as he guides her to a seated or lying position

The nurse had been caring for a patient in a hospice facility for 1 month. When the patient dies, the family invites the nurse to attend the calling hours and funeral. What is the most appropriate action for the nurse to take?

Attend the services, if she wishes to do so, as this can help to diffuse the nurse's feelings of loss and can be meaningful to the family.

The nurse is a member of the ethics committee. An alert, oriented, and competent 87-year-old man has asked to have a DNAR (AND) prescription put on his chart. The patient's family does not agree with his decision and requests the ethics committee to intervene on their behalf. The ethics committee would most likely use which model in this patient's case?

Autonomy

The emergency department nurse cares for a 17-year-old adolescent who is diagnosed with cervical cancer secondary to human papillomavirus. The patient declines treatment, saying, "I don't want my parents to know I have been sexually active, and if they find out about the cancer, they'll figure out the rest of it." The nurse explains the risk of death if the cancer is not treated, but the patient continues to refuse therapy. What conflicting principles is this nurse facing as the result of this patient's choices?

Autonomy versus nonmaleficence

What action is most important in limiting the nurse's risk of back injuries?

Avoid manual lifting by using assistive devices as often as possible.

35-year-old female comes to the clinic for her annual physical. Upon examination, the nurse palpates a lump in the left breast. She informs the client of the finding and the client responds, "Yes, I found it a few months ago too but just didn't want to think about it." The nurse recognizes that this client has been using which approach to coping with the lump?

Avoiding

The nurse is caring for a patient in a persistent vegetative state (PVS). Which finding is inconsistent with this diagnosis?

Aware of family, but can't respond to them

A patient who was prescribed furosemide (Lasix) is deficient in potassium. Which of the following is an appropriate nutritional goal for this patient? The patient will increase his consumption of:

Bananas, peaches, molasses, and potatoes

Donovan has been diagnosed with stage 4 cancer. He prays he will live to see his 20-year-old daughter get married in a year. Which stage of the Kübler-Ross stages of dying and grief is he experiencing?

Bargaining

A patient states that many of his friends told him to ask for Valium or Ativan to help him sleep while hospitalized. The nurse knows that nonbenzodiazepines (such as Ambien) are often preferred over benzodiazepines (Ativan or Valium). Why is this?

Benzodiazepines produce daytime sleepiness and alter the sleep cycle.

Which term describes the period of time after a spouse dies when a person adjusts to the change in his or her life?

Bereavement

The nurse is caring for a patient with a nursing diagnosis of Activity Intolerance secondary to cardiac disease that causes the patient to produce less energy than is expended with activity. Which theory of health and wellness would support this nursing diagnosis?

Betty Neuman

A client's risk of breast cancer is dramatically increased because both her sister and her mother have had breast cancer. Which of the multidimensional aspects of health does this scenario illustrate?

Biological factors

The nurse is teaching an older female patient how to manage urge incontinence at home. What is the first-line approach to reducing involuntary leakage of urine?

Bladder training

The nurse is assessing an intubated patient who returned from coronary artery bypass surgery 3 hours ago. Which assessment finding might indicate that this patient is experiencing pain?

Blood pressure 160/82 mm Hg

The nurse is assessing a client who does not speak English. He returned from surgery 3 hours ago. Which assessment finding might indicate that this client is experiencing pain?

Blood pressure 165/88 mmHg

The nurse receives the following report on four patients on the medical-surgical unit. Which patient will the nurse attend to first?

Blood pressure 90/50 mm Hg, heart rate 40 beats/min, rates chest pain at 8 on a 0 to 10 pain scale

A patient who sustained a leg laceration in an industrial accident is brought to the emergency department. The area around the laceration is red, swollen, and tender. Which substance is responsible for causing this response?

Bradykinin

The left pupil of a patient fails to accommodate. This finding may reflect an abnormality in which cranial nerve?

CN III

A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved?

CN VII and CN IX

Upon assessment, the nurse identified a positive Trousseau's sign. What electrolyte is of concern?

Calcium

Assume all of the following written instructions about digoxin provide correct information for patient care. Which one is best worded for patient understanding?

Call your provider if you notice that objects look yellow or green.

The physician has ordered a complete blood count for a 6-year-old child. When the nurse enters the room, she finds the child sobbing uncontrollably. His mother tells him to "shut up and act your age." How should the nurse proceed?

Calmly approach the child and tell him what is going to happen.

The department of nursing at a local hospital is considering changing to charting by exception (CBE). A major disadvantage of CBE is that it:

Can increase the risk of omissions in patient care

A 56-year-old woman provides care to her 91-year-old widowed father. She says she is frequently fatigued and that she no longer socializes with her friends. "I'm so busy taking care of my dad. It's really hard work because he is bedridden. Sometimes it breaks my heart when I have to feed and bathe him. He always seemed so strong when I was a child." The most appropriate nursing diagnosis for this woman is

Caregiver Role Strain

An older adult patient with dementia is seen at the clinic for a physical examination. The son tells the nurse, "I don't know how much more of this I can do. There is so much work involved in just getting my dad out of bed in the morning, and I can't communicate with him. I'm just so tired." The nurse recognizes that the son is most likely experiencing:

Caregiver role strain

The nurse in the intensive care unit is providing care for only one patient, who was admitted in septic shock. Based on this information, which care delivery model can you infer that this nurse is following?

Case method

The 80-year-old patient on the medical-surgical unit says to the nurse, "My vision is blurry and I see halos around lights. The glare from the sun really bothers me." Upon assessment, the nurse notes a cloudy film over the lens of the eye. Based on the patient's complaints and the nurse's assessment, the nurse associates these findings with which of the following?

Cataracts

A client reports taking acetaminophen (Tylenol) to control osteoarthritis. Which instruction should the nurse give the patient requiring long-term acetaminophen use?

Caution the patient against combining acetaminophen with alcohol.

The nurse caring for several patients on the intermediate care unit considers which of the following patients to be most at risk for developing an infection? A patient with a/an:

Centrally venous catheter

The nurse is obtaining a bowel elimination history from her 80-year-old patient. The patient states, "Sometimes when I go to the bathroom I push real hard, hold my breath, and plug my nose." Which action should the nurse take first?

Check the patient's medical history for heart disease, glaucoma, increased intracranial pressure, or a new surgical wound.

During morning care, the patient asks the nurse to shave him with a disposable razor. Before shaving him, the nurse should:

Check to see whether the patient is taking anticoagulants

A mother watches the nurse perform an assessment on her newborn and asks the nurse why she is doing things like "stroking the bottom of his feet." The nurse should respond, "I'm:

Checking to see if your baby has the reflex responses we anticipate"

A patient is brought to the emergency department after inhaling mercury. The nurse should be alert for which acute adverse effects associated with mercury inhalation?

Chest pain, pneumonitis, and inflammation of the mouth

During an assessment, the nurse notices that a client's breathing pattern follows a cycle of progressively increasing in depth, then progressively decreasing in depth, followed by a period of apnea. Which appropriately describes this respiratory pattern?

Cheyne-Stokes respiration

Using structural-functional theory, the nurse is working with a family going through a divorce. As the nurse plans the sessions, what will be the focus?

Children developing healthy coping patterns.

A year after Emma's death, Philip is still unable to return to work. His mother has moved in to care for the twins and Philip feels depressed and withdrawn. What type of grief is Philip experiencing?

Chronic grief

Which patient does the nurse classify as facing the highest surgical risk?

6-month-old with congenital heart anomaly and early stage liver disease

For which patient can the nurse safely delegate morning care to the nursing assistive personnel (NAP)? Assume an experienced NAP, and base your decision on patient condition. Assume there are no complications other than the conditions stated.

62-year-old who underwent surgical repair of a bowel obstruction 2 days ago

The nurse is assessing the pain level for a client with Alzheimer's disease using the Pain Assessment in Advanced Dementia (PAINAD) Scale. The client displays Cheyne-Stokes respirations, occasional groaning, facial grimacing, fidgeting, and distraction by touch. Based on these assessment findings, what would the nurse rate the client's pain level? Enter numeral only.

7

A nurse is teaching wellness to a women's group. The nurse should explain the importance of consuming at least how much fluid to promote healthy bowel function (assume these are 8-ounce glasses)?

7 to 8 glasses a day

A 55-year-old patient returned to the medical-surgical unit after undergoing a right hemicolectomy (abdominal surgery) for colon cancer. Which of the following is an appropriate, correctly written nursing order for this patient?

7/12/15 Encourage use of the incentive spirometer every hour while the client is awake—D. Goodman, RN

The nurse is instructing a new parent on the proper positioning of the infant car seat will explain that the infant or child may be positioned forward facing in an automobile at what weight?

9 kg (20 lb)

A client's average normal temperature is 98°F. Which of the following temperatures would be expected during the night in this healthy, young adult client who does not have a fever, inflammatory process, or underlying health problems?

97.2°F

The nurse is concerned that an African American client is experiencing cyanosis. Which of the following signs of cyanosis would the nurse look for in this client?

A bluish tinge in the skin, tongue, and mucous membranes that does not blanch when pressure is applied

Many health providers define illness as pathology; however, people experience, rather than define, illness. How do most people experience illness?

A change in the way they feel or a disruption in their typical life

Which postoperative client is at highest risk for the development of postoperative hemorrhage?

A client with cirrhosis

Which of the following describes the difference between a collaborative problem and a medical diagnosis?

A collaborative problem requires intervention by the nurse and physician or other professional; a medical diagnosis requires intervention by a physician.

A client is diagnosed with stage IV terminal cancer. The nurse notices that one minute the client is depressed and crying, and the next minute he or she is throwing items across the room. According to Dr. Elisabeth Kübler-Ross, which statement best explains the client's behavior?

A person may go through two or three stages of grief at the same time.

Which describes an ethical dilemma?

A pregnant woman may miscarry if she takes a strong chemotherapy agent, but if she doesn't, her cancer will progress quickly.

The client arrives in the emergency department after a motor vehicle accident and was hemorrhaging at the scene. Nursing assessment includes BP 80/34 mmHg, pulse rate 120 beats/min, and respirations 20 breaths/min. Which is the cause of these assessment changes?

A problem with the volume of blood in circulation

According to the gate-control theory of pain, which type of fibers inhibit the client's perception of pain?

A-delta fibers

Which term refers to the movement of a drug from the site of administration to the bloodstream?

Absorption

Which process requires energy to maintain the unique composition of extracellular and intracellular compartments?

Active transport

A client incorporates alternative healthcare into her regular health practices. For which alternative therapy should the patient visit a formally trained practitioner?

Acupuncture

A young adult with a severe episode of asthma bronchoconstriction comes to the emergency department with signs of respiratory distress. When the nurse performs the admission assessment, she notes that the patient is not able to say where she is or the time. Which nursing diagnosis is probably most suitable for this patient?

Acute Confusion

Which statement best describes adaptation in relation to sensory perception?

Adaptation is how a person becomes accustomed to a sound or odor that is present for an extended period of time.

The health-care provider prescribes 0.9% sodium chloride to infuse at 100 mL/hour. The nurse hangs a new 1 liter bag at 0800. The nurse returns to the room at 1200 and notices only 200 mL of the solution has infused. What is the most appropriate intervention for the nurse to perform?

Adjust the rate of infusion to 100 mL/hour and document the intake.

A client with poor skin turgor, dry mucous membranes, and decreased urinary output is admitted to the acute care facility. Which actions should be included in the plan of care? Select all that apply.

Administer IV and oral fluids.

The nurse administered the narcotic Demerol, 50 mg PO at 1400 to a patient with pain rated as 9 on a 0 to 10 scale. At 1430, the patient stated that the medication was not working and requested to have morphine IV, which the provider had prescribed for severe pain. What is the nurse's best evaluation of this situation?

Administering Demerol PO was not the best nursing intervention in this situation.

Which of the following is considered a primary care service?

Administering childhood immunizations

Which of the following is an example of an illness prevention activity?

Administering immunization for HPV

Which of the following sets of vital signs are all within normal limits for patients at rest?

Adolescent: T 98.2°F (oral), HR 80, RR 18, BP 108/68

An elderly female, adequately nourished, was admitted to the skilled nursing facility 3 months ago. Since then, she has had a significant weight loss and become frail. Her appetite and activity level are reduced and she has lost interest in interacting with other patients. What would the nurse suspect the reason for her condition to be?

Adult failure to thrive

A nursing student recognizes that a clients laboratory results are abnormal but does not know the reason why. In which stage of informal learning is this student ?

Advanced beginner

Which situation below best depicts a mid-life crisis?

After the couple's daughter leaves for college, the husband quits his job and decides to "see the world."

Which situation is the most conducive to conducting a successful interview of an elderly woman whose husband and two children are in the hospital room visiting and watching television? The woman is alert and oriented.

After the family leaves, ask the client whether she is comfortable and willing to answer a few questions.

Which criterion might be used in structure evaluation?

"A defibrillator is present on each client care area."

The nurse is presenting a workshop on stress and adaptation to a group of teenagers at the local high school. A teenager approaches the nurse and says, "Sometimes I feel stressed when I have to take a test. I feel my heart is going a little faster but I do focus better. What do you think?" What is the most appropriate response by the nurse?

"A little stress is not necessarily a bad thing. It can help you to focus."

The new nursing student is caring for a 75-year-old patient on the medical-surgical unit. The patient states, "I hope I can go home soon. I want to get back to the gym. I like to do a little walking on the treadmill and lift some light weights." Which response by the nursing student demonstrates the use of ageism?

"At your age, you need to be careful with exercise."

The nurse is teaching nursing assistive personnel (NAP) how to give a complete bed bath. Which instruction should the nurse include?

"Bathe the patient from head to toe, cleanest areas first."

Which statement made by the nurse is an example of stereotyping?

"Be sure to take your shoes off when entering a Japanese family's home."

A patient newly diagnosed with breast cancer tells the nurse, "I'm worried I won't survive to see my children grow up." Which response by the nurse best conveys concern and active listening?

"Breast cancer is a serious disease; I can understand why you're worried."

Which assessment question helps assess immediate memory?

"Can you repeat the numbers 2, 7, 9 for me?"

While the nurse is performing a nutritional assessment her patient states, "I am on a vegan diet. I have been a vegan for 10 years. What do think?" What is the best response by the nurse?

"Can you tell me about the foods you eat along with any other supplements you take?"

Before the end of the shift, the nurse records the occurrences for each patient in the electronic medical record. Which statement below indicates that the nurse understands the main principle of accurate charting?

"Charting communicates to members of the healthcare team the patient's care and responses during my shift."

The nurse is caring for a client who is in a persistent vegetative state. A family member who visits notices the client is crying and informs the nurse the client is improving and responding to stimuli. What is the nurse's best response?

"Clients in a persistent vegetative state have reflex reactions such as crying"

A new mother comments on the expense of formula and asks the nurse why she cannot feed the baby the same milk that the rest of the family drinks. Which is the best response that the nurse can provide to the mother?

"Cow's milk can cause gastrointestinal bleeding and stress on the kidneys, and it can lead to iron-deficiency anemia."

The patient tells the nurse, "I have terrible insomnia. It seems as though I am exhausted all the time." What question is most appropriate for the nurse to ask this patient?

"Do you have trouble falling asleep or staying asleep?"

The nurse meets with patients who quit smoking, or are planning to quit. Which statement made by a patient would lead the nurse to conclude that that patient is in the maintenance stage of change?

"Each day I don't smoke, I put money that I would have spent in a jar to pay for a vacation."

The nursing student is caring for a group of patients on the medical-surgical unit who need to be ambulated during the day. She tells the primary nurse, "Some of my patients feel so sick but want to get out of bed. Others say they feel well but don't want to get out of bed. What should I do?" What is the most appropriate response by the nurse?

"Get the patients out of bed who want to get up, and help the others to ambulate later in the day."

A mother comes to the healthcare clinic for a regular health examination for her 5-year-old son prior to kindergarten admission. Which comment by the mother would indicate the need for follow-up questions to the mother?

"He's not a good boy like my other son."

The nurse is seeing a 20-year-old client with a urinary tract infection (UTI) at the women's health clinic. The client says to the nurse, "It seems to me more women get urinary infections than men. Why is this?" What is the best response by the nurse?

"Hormone changes during pregnancy and pressure of the uterus on the bladder can make women more prone to UTIs."

An 80-year-old healthy male sees the nurse practitioner at the doctor's office. He states, "I sit around a lot and now I notice my legs seem to get tired when I walk." What is the most appropriate response by the nurse?

"How do you feel about joining a regular exercise program at the senior center?"

The instructor is teaching the nursing students about electronic health records (EHR). Which student statement indicates the need for further instruction?

"I am proficient with a computer; therefore, I am completely prepared to use the EHR in any institution."

The nurse teaches a mother of a preschool-age child about expected development. Which comment by the parent indicates she understands the information?

"I am saving to buy her the roller skates she's been asking for."

The school nurse is teaching a group of middle school students how to prevent tinea pedis. Which remark by a student provides evidence of learning?

"I can contract the infection by walking barefoot in the gymnasium's showers."

The nurse provides client education regarding hypertension prevention and management. Which of these statements indicates that the client understands the instructions?

"I can lose some weight to help lower my blood pressure."

A patient who sustained a spinal cord injury will perform intermittent self-catheterization after discharge. After discharge teaching, which statement by the patient would indicate correct understanding of the procedure?

"I can use clean, rather than sterile, technique at home."

The nurse is performing an initial interview on a 75-year-old male. Which of the following statements by this patient indicates the need to perform a special needs assessment?

"I have fallen twice at home in the past 6 months, so my wife thinks I need a walker."

Which comment made by a woman in her early 50s would be a cue indicating the need for further assessment for a problem?

"I have to write myself notes because I'm getting so forgetful."

The nurse is teaching a clinic patient about hypertension. Which statement by the patient suggests that he is present-oriented?

"I know I need to give up foods that contain a lot of salt, but with teenagers in the house it is very difficult."

After instructing a mother about nutrition for a preschool-age child, which statement by the mother indicates correct understanding of the topic?

"I know that lifelong food habits are developed during this stage of life."

According to Elisabeth Kübler-Ross's five stages of grieving, which statement indicates a client is in the bargaining stage of grief?

"I know there is no cure for this disease, but I want to live long enough to see my granddaughter get married. I will be a better person in order to have that."

The nurse administers two blood pressure (BP) medications to a patient and asks the certified nurse assistant (CNA) to obtain a BP reading in 30 minutes. The CNA states, "I just took his BP." What is the most appropriate response by the nurse?

"I need to check the patient's response to the BP medications."

A 60-year-old woman complains of muscle weakness, constipation, nausea, and frequent urination, and is displaying bizarre behavior. The woman takes prescribed thiazide diuretics. What statement made by the patient might be an additional cause of her symptoms?

"I take calcium supplements to prevent osteoporosis and eat lots of dairy foods."

A 30-year-old patient newly diagnosed with type 2 diabetes states to the nurse, "If glucose is so important, then I think as long as my blood sugar is high I must be doing well." What is the most appropriate response by the nurse?

"I understand how you are thinking; however, a high glucose level does not mean that there is more fuel available for your body's cells. Because you have diabetes, your body cells will allow only a limited amount to enter. The cells can't use the excess glucose."

An 80-year-old man arrives in the emergency department after suffering a severe heart attack. His condition is deteriorating and the physician informs the wife, also an older adult, that they do not expect him to live. The wife begins to cry uncontrollably and tells the nurse, "We have been married for 60 years. What am I going to do?" What is the most appropriate response by the nurse?

"I understand that this is an incredible and unexpected loss for you."

The nurse is talking to a patient with chronic pain secondary to psoriatic arthritis in multiple joints about developing a pain management program. Which goal identified by the patient would be realistic for the program?

"I want to control the pain enough to allow me to sleep through the night."

At a first aid station on a marathon route, a patient after the race complains of headache, muscle cramps, weakness, nausea, and confusion. Which statement made by the patient might explain these symptoms?

"I was really thirsty after the race. I drank several large bottles of water."

The nurse is teaching a female patient with stress incontinence how to perform pelvic floor muscle exercises (PFMEs). Which of the following statements indicates that the patient understands the procedure?

"I will keep the contraction and relaxation times equal."

The nurse instructs a woman about providing a clean-catch urine specimen. Which of the following statements indicates that the patient correctly understands the procedure?

"I will wipe my genital area from front to back before I collect the specimen midstream."

After a physician discusses cancer treatment options with a patient, the patient asks the nurse which treatment he should choose. Which response by the nurse is best?

"I'll give you some information about each option."

The nurse is caring for a patient with severe arthritis and notices a written pain medication order that appears to have an extremely high dose. She places a call to the physician to question the prescription dose. Which statement below best describes an assertive communication style by the nurse in interacting with the physician regarding the pain medication order?

"I'm concerned about the medication dose you prescribed for Mrs. Garcia."

The nurse must insert a nasogastric (NG) tube into a patient with a bowel obstruction. Before inserting the tube, the nurse must explain the procedure to the patient. Which explanation by the nurse is best? Assume that all provide correct information.

"I'm going to insert a tube through your nose into your stomach to prevent you from vomiting."

The certified nursing assistant (CNA) tells the nurse: "I can help you with your assessment." What is the most appropriate response by the nurse?

"If you will obtain the vital signs and place them in the chart then that would be a big help."

Today is the last day of work on the medical-surgical unit for a nurse who has decided to work in home care. A patient asks her why she is leaving to work in home care. Select a response that best illustrates the advantages of home care.

"In home care, I can see my patients in their personal environment; this will help me understand them more and allow me to give personalized care."

A patient in a cancer clinic says to the nurse, "I'm just so angry. I feel like God is punishing me. I know this is a bad way to think, but I don't deserve to die of cancer." What is the most appropriate response by the nurse?

"It is normal for you to feel this way. I'm interested in hearing more about how you feel."

A 75-year-old white female patient says, "I've heard that women live to an older age than men do. My husband and I are the same age, so I am afraid I will have to spend some years without him. That really worries me." Which answer is based on correct information?

"It is true that women have a longer life expectancy at birth. However, life expectancy measured at age 65 is almost the same for both sexes. You are both well past 65."

The nurse manager of the medical intensive care unit formed a group to help her staff cope with stress more effectively. Which of the comments by group members will lead the manager to evaluate the group as successful?

"It really helps me to share feelings about how hard it is to see pain and suffering every day."

The home care nurse visits a client who wears oxygen at bedtime. She smells cigarette smoke when entering the home. What should she say to the client?

"It smells like someone has been smoking in here. Do you realize that oxygen is highly combustible?"

mother brings her 4-month-old infant for a well-baby checkup. The mother tells the nurse that she would like to start bottle feeding her baby because she cannot keep up with the demands of breastfeeding since returning to work. Which response by the nurse is appropriate?

"Make sure you give your baby an iron-fortified formula to supplement any stored breast milk you have."

The mother of a 6-year-old child says to the pediatric nurse, "My son had such a bad case of the measles. I hope he doesn't get them again." What is the most appropriate response by the nurse?

"Measles is a disease that once you've had it, you won't get it again. The body has learned to make cells that will fight off any future exposures."

A nursing instructor asked his nursing students to discuss their experiences with charting assessment data. Which comment by the student indicates the need for further teaching?

"My patient was really quiet and didn't say much, so I charted that he acted depressed."

A nursing student attending a conference on grief says to one of the presenters, "The patient I cared for last week in clinical told me she cried for 4 months after she lost her cat. Isn't that an excessive amount of time to cry over a cat?" What is the most appropriate response by the presenter?

"No, all people grieve differently depending on how meaningful the loss was in their life."

The nursing instructor is teaching the student about occurrence reports. Which statement by the student indicates an understanding of the purpose of occurrence reports?

"Occurrence reports track problems and identify areas for quality improvement."

An elderly patient is covered under Medicare. She is scheduled for discharge and tells the nursing student that several therapists will come to her home to help her regain functional abilities. The patient then asks, "Why can't I just stay in the hospital and receive this type of care?" What is the nursing student's best response?

"Once you have reached your reimbursable length of stay and your condition is stable, it is more cost effective to provide you with home healthcare."

The nurse is caring for a patient with a fluid and electrolyte imbalance. She asks the certified nursing assistant (CNA) to obtain the intake and output. Which of the following statements below best describes the most appropriate communication to the CNA in delegating this task?

"Please record all food and fluid the patient takes in and the amount of all urine, stool, and emesis for the next 48 hours."

The nurse teaches a class for new parents promoting safe sleep for infants. The nurse determines a participant understood the important safety points when a parent makes which statement? "I will

"Put my son on a firm crib mattress on his back and remove all padding"

The daughter of an 82-year old patient tells the nurse, "When I ask my dad to do something, it takes him a long time to respond to me. But he does do what I ask." Which is the most appropriate response by the nurse is?

"Reaction time slows in older adults, so it takes him more time to process your requests."

The nurse is caring for a male patient who states, "I have been smoking two packs of cigarettes a day for 20 years and now my nurse practitioner wants me to take vitamins. Do you think I need to take vitamins?" What is the most appropriate response by the nurse?

"Smokers use vitamin C faster than do nonsmokers, and is linked to iron deficiency. You can either eat more foods containing vitamin C and iron or take dietary supplements."

The nursing student is assigned to care for a patient who has just been diagnosed with advanced stage cancer. The patient is very upset and crying. The nursing student states to her instructor, "I don't know what to do. My patient just can't stop crying." What is the best response from the instructor?

"Sometimes just sitting with patient and remaining silent can be the best care."

A 15-year-old patient complains of left ankle pain after being tackled while playing football. He asks the nurse what tests he needs to have to determine whether he has a strain or a fracture. How should the nurse reply?

"Sprains, strains, and fractures have similar symptoms at first; you will need an x-ray of the joint to be certain."

The nursing student asks his instructor, "Why do some of my patients get a headache when they have stress and others cry?" The most appropriate response by the instructor is which of the following?

"Stress responses can be physical, mental, behavioral, and spiritual."

A patient being admitted in hypertensive crisis informs the nurse that he stopped taking his blood pressure medication 3 weeks ago. Which response by the nurse is best?

"Tell me more about your experience with your high blood pressure medication."

A patient who is being discharged asks the nurse, "Can I take you out for dinner to show my appreciation for all that you have done for me? I really like you." The nurse's best response is which of the following?

"Thank you; however, I have to refuse, even though the thought is appreciated."

The nurse is seeing a teenage client with a urinary tract infection (UTI) at the clinic. The client remarks, "It seems to me more women get urinary infections than men. Why is this?" What is the nurse's best response?

"The female urethra is shorter than that of the male, making women more prone to infections."

A patient diagnosed with macular degeneration asks the nurse to explain his condition. Which statement by the nurse best describes macular degeneration?

"The portion of your eye called the macula, which is responsible for central vision, is damaged."

A patient asks the nurse why there is no vaccine available for the common cold. Which response by the nurse is correct?"

"The virus mutates too rapidly to develop a vaccine."

The patient in the ambulatory clinic asks the nurse in the billing office, "Why do I have to pay $10.00 for this visit when I have insurance?" What is the nurse's most appropriate response?

"This a co-payment you are required to pay per clinic visit as described in your insurance plan."

A client's caregiver frantically calls the hospice nurse because the client stops breathing for short amounts of time and then takes slow, shallow breaths. What is the nurse's best response?

"This breathing pattern indicates death may occur in hours or days."

The patient at the clinic says to the nurse, "My doctor checked my eyes and told me my vision was 20 over 100 [20/100]. What does that mean?" What is the best response by the nurse?

"This could be nearsightedness. Your vision for seeing objects up close is better than your vision for seeing things in the distance."

When asked to sign the surgical consent form, the patient has questions. The nurse notifies the surgeon, who talks with the patient again and then tells the nurse the questions have been answered. When the nurse again explains the purpose of the consent form to the patient, the patient says, "The doctor says this surgery is necessary. Do you think it is really necessary?" What is the nurse's best response?

"This is a decision only you can make. What concerns do you have?"

A father brings his 18-month-old child to the pediatric clinic for a well-baby checkup. The father tells the nurse that he is concerned because his child's legs are bowed. Which response by the nurse is appropriate?

"This is a normal finding in children for 1 year after they begin walking."

The nursing student tells her instructor, "My patient is Jewish and when I tried to teach her about her antihypertensive medication she said, 'I'd rather eat chicken soup than take those medications.'" What is the most appropriate response by the instructor?

"This is common folk medicine among some Jewish people. You can talk to her about taking her medications and eating chicken soup."

The graduate nurse tells her preceptor that the newly admitted patient has a strange living arrangement, because she lives in a household that consists of two aunts, a grandparent, a niece, a nephew, and her best friend. What is the preceptor's best response?

"This is considered an extended family and is not unusual."

The parents of a newborn voice concern regarding looser stools that the newborn is experiencing after each breastfeeding. What would be the nurse's best response?

"This is normal because newborns have looser stools due to immature intestines."

The mother of a 1-month-old infant states to the examining nurse, "There is something wrong with my baby's eyes. She seems to be cross-eyed." What is the most appropriate response by the nurse?

"This is not uncommon in infants in their first 2 months of life."

The nursing student is preparing to administer an intramuscular (IM) injection to her patient. She states to her instructor, "I'm going to administer this medication in my patient's buttocks at the dorsogluteal site." What is the most appropriate response by the instructor?

"This may not be the best site owing to proximity of the sciatic nerve."

While the nurse assesses a newborn of African American descent, the mother points out a blue-black Mongolian spot on the newborn's back and asks, "What's that? Is something wrong with my baby?" Which response by the nurse is best?

"Those spots are quite common and typically fade with time."

The 75-year-old patient is preparing for discharge and tells the case manager, "I don't know what I am going to do when I get home. I cannot afford the medications the doctor has ordered for me." What is the case manager's most appropriate response?

"We can have a social worker see you when you get home."

The nurse has instructed a group of parents about common adolescent behavior. Which comment by the parent would indicate the most urgent need for further discussion?

"We don't keep alcohol in the house, so that's at least one thing we don't need to worry about."

A 62-year-old patient is admitted to the hospital with hypertension. Which question by the nurse is most important when performing the initial assessment interview?

"What is the greatest concern you are dealing with today?"

Which are appropriate questions a nurse could ask to help establish a client's goals at end of life? Select all that apply.

"What is your pain goal, on a scale of 0-10?" "Whom would you like to have in the room with you?" "Is there anything you would still like to do?"

As a nursing student and nurse, you will encounter many patients from diverse cultures. When caring for a culturally diverse patient, what initial question can you ask your patient that will best assist you to improve your cultural competency?

"What matters most to you about your illness and treatment?"

The nurse is beginning her assessment on a 35-year-old woman. The patient appears to be of Asian descent. As part of the nurse's cultural assessment, what question is most appropriate for the nurse to ask pertaining to race prior to documenting the patient's race?

"What race do you identify with and what name do you call it?"

The nurse is performing a sleep assessment for a newly admitted patient. He says his sleep habits are satisfactory and that he normally feels well rested. What would the nurse ask next?

"What time do you usually go to bed and awaken?"

A nursing instructor is guiding nursing students on best practices for interviewing patients. Which of the following comments by a student would indicate the need for further instruction?

"When I give my patient his pain medication, I will have time to ask questions."

The nurse is interviewing a patient who has a recent onset of migraine headaches. The patient is very anxious and cannot seem to focus on what the nurse is saying. Which of the following would be best for the nurse to say to begin gathering data about the headaches?

"When did your migraines begin?"

A patient is not feeling well at home and comes to the emergency department to be evaluated. In the initial nursing interview, what is the first question the nurse would ask?

"Why did you come to the hospital today?"

An 18-year-old woman comes to the obstetrician's office and is informed that she is 6 weeks pregnant. Which statement by the woman is the nurse most concerned about?

"With my current job, I won't be able to keep up with prenatal visits so I will read some books on prenatal care."

A 30-year-old female comes to the emergency department with visible bruises to her face and arms. She tells the nurse: "My husband has been hitting me." The most appropriate response by the nurse is which of the following?

"Would you like me to contact our domestic violence advocate for you?"

The patient comes to the emergency department complaining of chest pain. What question by the nurse will encourage the patient to provide the most details about the pain?

"Would you please tell me more about the pain you are having?"

A patient with morbid obesity was enrolled in a weight loss program last month and has attended four weekly meetings. But now he believes he no longer needs to attend meetings because he has "learned what to do." He informs the nurse facilitator about his decision to quit the program. What should the nurse tell him?

"You have done well in this program. However, it is important to continue in the program to learn how to maintain weight loss. Otherwise, you are likely to return to your previous lifestyle."

Which statement or question by the nurse manager demonstrates an assertive approach?

"You must assess and document pain status for every patient."

A patient who has been hospitalized for weeks becomes angry and tells the nurse who is caring for him, "I hate this place; nobody knows how to take care of me or I'd be home by now." Which response by the nurse is best in this situation?

"You seem angry; what's going on that makes you hate this place?"

After a client dies as the result of a brain tumor, his son says to the nurse, "You'll probably think I'm terrible, but I'm glad he can finally rest in peace." Which is the nurse's best response?

"Your feelings are a normal response to watching your loved one suffer."

A teenage boy was hospitalized 3 weeks ago. He has been confined to bed throughout his hospital stay because of a crushed pelvis. His parents tell the nurse, "Our son is just staring off into space; he won't talk to us. We are worried because he has not even listened to his iPod, watched television, or played his video games for 2 days. That is so unlike him." What is the best response the nurse can make?

"Your son had a major injury, and his immobility might be causing him to feel isolated and depressed."

The pediatric nurse is going to a preschooler class to do a presentation on teeth brushing. Prior to the start of class, she spends some time meeting and talking with the students. Which of the following statement(s) by the preschoolers indicates normal development for this group? Select all that apply.

- "After our class, I am going to read my book. I love my book." - "You should never steal anything from anyone." - "I can count to 20."

The mother of 6-year-old twins says to the pediatric nurse, "My husband and I keep a gun in our home. Do you have any safety tips for us?" The most appropriate response by the nurse is which of the following? Select all that apply.

- "Be sure to keep your gun unloaded and in a secure and locked cabinet." - "Ammunition for your gun should be stored in a different location from the gun."

The patient diagnosed with inadequate closure of the mitral valve is scheduled for surgery and asks the nurse, "Why does it matter if my valve leaks?" What is the nurse's best response to explain why this mitral valve needs to be repaired?

- "Blood backflows from the left ventricle to the left atrium, reducing available blood flowing to the body."

A student nurse is discussing the diet required in client with hypertension who is also at risk for osteoporosis and takes a diuretic. Which dietary change designed to control electrolytes and fluids in this client noted by the nurse indicates a need for further teaching? Select all that apply.

- "Clients with hypertension should follow a very low-carbohydrate diet." - "Hypertensive clients should ensure minimal phosphorus intake."

Which questions should the nurse ask the client when assessing for peripheral vascular deficits? Select all that apply.

- "Do you have numbness in your hands and feet?" - "Are there any sores on your legs that never heal?" - "What makes the pain worse, elevating your legs or dangling them?"

The nurse is preparing to interview a client with an extensive cardiac history. Which questions would the nurse ask of a client in a focused assessment of the family history? Select all that apply.

- "Have any of your siblings experienced a heart attack or stroke?" - "Who on your father's side of the family has heart disease?"

A client is given a diagnosis of terminal cancer, and the health-care provider suggests hospice services for the family. The family is hesitant and asks the nurse what hospice can provide. Which responses given by the nurse are appropriate? Select all that apply.

- "Hospice services assist the family with funeral planning." - "Hospice services ensure the client is comfortable and the pain is controlled." - "Hospice services allow the client to preserve dignity during the dying process." - "Hospice services provide spiritual care for the client within the client's culture." - "Hospice services can provide chemotherapeutic medications for treatment."

When conducting the patient interview, which of the following statements by the nurse are appropriate? Select all that apply.

- "I can see that you are in pain right now. Would you like your pain medication and then I can complete the interview a little later?" - "I am going to be completing your interview now. Is this a good time for you?" - "Have you noticed any changes in your pattern of sleeping?"

Which statement(s) by the new graduate nurse indicates a need for further instruction about documentation? Select all that apply.

- "I can wait until the end of the shift to document my care." - "Charting every 2 hours is the most appropriate way to document nursing care." - "I should chart as soon as possible after nursing care is given."

The nurse believes that a patient may be experiencing a lot of stress at home. The patient is angry and states, "It is too much for me to handle. You don't know what I am going through." What is the most appropriate response(s) by the nurse? Select all that apply.

- "I don't know what you are going through, can you tell me more?" - "How long have you been dealing with this stress?" - "How do you usually manage your stress?"

The home health nurse is caring for a 75-year-old patient with severe arthritis of her hands and fingers. The patient states, "I can't use these childproof safety lock caps because I can't open them." What is the most appropriate response(s) by the nurse? Select all that apply.

- "I see this is difficult for you. Do you have any family members or friends who can help you?" - "We can ask the pharmacist not to put childproof caps on your medications; you may need to sign a form."

Which of the following statements are reflective of barriers to communication? Select all that apply.

- "I see you had a heart attack. Why are you still smoking?" - "I know you are having pain in your knee. I will check your vital signs before getting your pain medications." - "The nursing assistant told me you are having back pain. I'll get your pain medication now." - "Let's talk about all the possible causes and treatments for chest pain."

A nurse is teaching a client how to promote venous circulation. Which statements by the client indicates understanding of the teaching? Select all that apply.

- "I will keep my legs elevated when I am sitting in the recliner." - "I will take a walk around the block in the morning and afternoon." - "I will drink at least six 8-ounce glasses of water every day." - "I will attend a smoking cessation class at the YMCA."

The nurse is providing care to a pregnant woman in preterm labor. The patient is 32 weeks pregnant. Initially, the patient states, "I've gained 30 pounds. That should be enough for the baby. Everything will be okay if I deliver now." After teaching the patient about fetal development, the nurse will know her teaching is effective if the patient makes which of the following statements?

- "If I deliver this early my baby is at risk for respiratory distress syndrome, a condition that can be life threatening."

The nurse is counseling a 17-year-old girl on smoking cessation. The nurse should include which of the following helpful tips in her education? Select all that apply.

- "Keep healthy snacks or gum available to chew instead of smoking a cigarette." - "Plan a time to quit when you will not have many other demands or stressors in your life." - "Reward yourself with an activity you enjoy when you quit smoking."

The nursing student is working with a primary nurse on the oncology unit. She says to the nurse, "How can I best help my patients' and to make their hospital stay a better experience?" What is the most appropriate response for the nurse to make? Select all that apply.

- "One of the very best ways is to listen to your patient and be attentive." - "It is good to think about your own strengths and weaknesses and how you cope with illness."

A sexually active high school student is asking about contraceptive devices. The nurse knows that the student understands the information when she states which of the following? Select all that apply.

- "STIs are major health consequences associated with sexual activity, and especially with unprotected sexual activity." - "Consistent and effective use of condoms can help prevent pregnancy."

A patient tells the nurse, "I'm having a lot of pain in my hip." Which response(s) by the nurse most likely would stimulate the patient to provide the most complete data? Select all that apply.

- "Tell me about your pain." - "How would you describe your pain?"

The nurse is providing teaching for a weight loss group on the cardiac dangers of obesity. Which statement, if made by the nurse, would be incorrect?

- "Tissue perfusion is diminished by obesity."

The nurse is caring for a patient on the medical-surgical unit. The patient states, "I really don't like to talk about my bowel movements, but what is considered a normal bowel movement?" What is the best response by the nurse? Select all that apply.

- "We can say normal frequency is anything from several times a day to once per week. It depends on your normal pattern." - "We also consider whether you have to strain with bowel movements, use laxatives, or have to rush to the toilet."

A nurse is performing cardiopulmonary resuscitation on an infant. When performing chest compressions, the nurse understands that the compression rate is at least:

- 100 times a minute

The nurse and nursing assistive personnel (NAP) are caring for a group of patients on the medical-surgical floor. For which of the following patients can the nurse delegate to the NAP the task of bathing? Select all that apply.

- 75-year-old patient newly admitted with dehydration - 92-year-old patient with stable vital signs who was admitted with a urinary tract infection - 56-year-old patient with chronic renal failure who has vital signs within his normal range

A client is in the emergency room with complaints of chest pain and dyspnea. What would be the most important assessment data to report to the physician?

- A pulse oximetry reading of 91% on room air

The nurse is selecting nursing interventions for her patient with diabetes. The nurse will select interventions using which resources available to her? Select all that apply.

- A standardized list of interventions - Interventions generated based on her knowledge base and past experiences

A nurse is reviewing lab data on a client with a BMI of 30.2 (obesity). What lab value would be most concerning?

- A total cholesterol level of 289 mg/dL

Which statement(s) is/are most accurate regarding values and beliefs? Select all that apply.

- A value is a standard or principle that has meaning and worth to an individual. - A belief is something one accepts as true.

Which older adult is experiencing normal aging changes of the urinary system? Select all that apply

- A woman who wakes up to void once during the night - A man who has difficulty getting a hard erection

The nurse is researching about perioperative errors. According to the Agency for Healthcare Research and Quality (AHRQ), in 2008, which information is accurate regarding preventable perioperative errors? Select all that apply.

- Accounts for 10% of all surgery-related deaths - Has a major financial impact on health-care facilities - Causes emotional and physical harm to clients.

The nurse explains to a patient that dressing changes will improve healing and decrease infection and then demonstrates the correct aseptic technique to the patient. The patient is asked to return a demonstration of this dressing change and to describe the reasons for it to the nurse. This example includes what learning domain(s)? Select all that apply.

- Active - Cognitive - Psychomotor

The nurse is caring for a client who is recovering from a new permanent colostomy secondary to colorectal cancer. The client received the first chemotherapy treatment 2 weeks ago and is beginning to experience alopecia. Which types of loss might this client be experiencing? Select all that apply.

- Actual loss - Physical loss

The nurse admits to the coronary care unit a patient diagnosed with an acute myocardial infarction. The patient's blood pressure reading is 86/38 secondary to an infusing nitroglycerine drip. Pulse rate is 120 beats/min and respirations are 14 breaths/min. The patient is pale and grimacing, and moans occasionally. What nursing diagnoses would the nurse anticipate for this patient? Select all that apply.

- Acute Pain - Risk for shock - Decreased Cardiac Perfusion

Which of the following is the most appropriate task(s) to be delegated to the licensed practical nurse (LPN)? Select all that apply.

- Administer oral pain medications - Insert an indwelling (e.g., Foley) catheter

Which of the following nursing activities represent direct care? Select all that apply.

- Administering a medication - Teaching a patient how to change a wound dressing

Which of the following factors influence normal lung volumes and capacities? Select all that apply.

- Age - Body size - Activity level

Which are types of reactions clients may have to administration of blood and blood products? Select all that apply.

- Allergic - Fluid volume overload - Febrile

A client lives alone. He is very weak, stays in bed most of the time, and becomes fatigued after taking only two or three steps with a walker. His personal hygiene is poor. He moves very slowly when doing even small tasks such as eating a meal. Which of the following are appropriate interventions for this patient? Select all that apply.

- Arrange for a home aide to assist with activities of daily living. - Assess the patient for symptoms of depression and memory loss. - Arrange for nutritious meals to be delivered to the patient's home.

Interventions for improving taste

- Assess for sores in the mouth - monitor dietary intake - provide oral hygiene - allow client to select favorite foods - encourage spices, salt substitutes, and seasonings

Place the steps for performing a tracheostomy or endotracheal suctioning in order.

- Assess the client's respiratory status, position in semi-Fowler's, and place linen-saver padding on the client's chest. - Don face shield/goggles and turn on suction using the lowest pressure. - Don non-sterile glove and test the suction. - Remove and discard gloves; then open the suction catheter kit. - Don gloves. Pour sterile saline into the sterile container. - Premeasure the catheter insertion distance. - Don sterile gloves. Attach the suction catheter to the connection tubing. - Placing the tip of the catheter in the sterile saline, suction a small amount of solution through the catheter. - Lubricate the suction catheter tip with normal saline solution. - Gently and quickly insert the suction catheter into tubing and apply suctioning. - Perform hand hygiene, then perform mouth care for the client.

The nurse has just completed wound care on her patient who has a large abdominal wound. What should the nurse do soon after this is completed? Select all that apply.

- Assess the patient's response to the procedure - Document the procedure in the nursing progress notes

Which of the following statements are true regarding professional standards of nursing assessment? Select all that apply.

- Assessment is a professional nursing responsibility. - Assessment helps the nurse identify problems and assign priorities for patient care. - Parts of nursing assessments can be delegated according to state practice acts and agency policies.

Which of the following are cues rather than inferences? Select all that apply.

- Ate 50% of his meal. - States, "I slept well." - White blood cell count is 15,000/mm3.

A patient diagnosed with hypertension is taking an angiotensin-converting enzyme (ACE) inhibitor. When planning care, which of the following outcomes would be appropriate for the patient?

- BP will be lower than 135/85 on all occasions.

The nurse admitting a new patient to the medical-surgical unit is conducting a dietary history. What information should the nurse include? Select all that apply.

- Basic eating habits - Food preferences - Attitude toward food - A body mass index (BMI)

The nurse's obligations in ethical decisions include which of the following? Select all that apply.

- Be a patient advocate. - Involve institutional ethics committees. - Improve one's own ethical decision making. - Respect patient confidentiality.

The nurse is caring for a patient who has cancer and is terminally ill. What are the most appropriate action(s) by the nurse in providing end-of-life care that will address the patient's cultural and spiritual needs? Select all that apply.

- Be an empathetic listener for the patient. - Allow the patient to participate in his spiritual rituals.

A client who had an ileostomy returns to the clinic and informs the nurse he or she is having difficulty with an odor coming from the ostomy bag. Which foods should the nurse instruct the client to avoid in order to decrease ostomy odor? Select all that apply.

- Beer - Asparagus - Cucumbers

The nurse is caring for a patient who experienced a stroke leaving the left side of the body paralyzed. The patient says, "I can still bathe myself," but the nurse performs the bath to make certain the patient gets clean. What ethical principles is the nurse violating with this behavior? Select all that apply.

- Beneficence - Autonomy - Nonmaleficence

Which of the following medications would you expect to be included in the treatment of a patient with congestive heart failure? Select all that apply.

- Beta-adrenergic agents - Diuretics

Comparing the changes in vital signs as a person ages, which statement(s) is/are correct? Select all that apply.

- Blood pressure increases; heart rate and respiratory rate decline. - Men have higher blood pressure than women until after menopause.

What are the functions of body fluids? Select all that apply.

- Body fluids maintain blood volume - Body fluids regulate body temperature - Body fluids transport material to and from cells - Body fluids facilitate the excretion of bodily wastes

What are two risk assessment tools used in the United States to evaluate a patient's risk for pressure ulcers? Select all that apply.

- Braden scale - Norton scale

Which area(s) should the nurse inspect when assessing for cyanosis in a dark-skinned patient? Select all that apply.

- Buccal mucosa - Palms - Tongue

Sources of Saturated and Trans-Fats

- Butter - egg yolks - chicken - packaged baked goods - processed foods

A nurse is reviewing clinical data on a client with a history of type 2 diabetes mellitus, hypertension, and tobacco use. What data is the most concerning?

- C-reactive protein of 3.2 mg/dL

Which of the following blood levels normally provides the primary stimulus for breathing?

- Carbon dioxide

The community health nurse is making a presentation on carbon monoxide (CO) poisoning at the neighborhood health fair. Which of the following will the nurse include in her presentation? Select all that apply.

- Carbon monoxide is a colorless, odorless, and tasteless gas. - Carbon monoxide poisoning causes many older adult deaths in cold weather months.

Your client is a healthy older adult who has comes to the health clinic because she reports not feeling like herself. When you are gathering data in your client's health history, she tells you that she is feeling more fatigue when walking up stairs and doing her normal household activities. What are normal physiological changes in the cardiovascular system that occur with aging? Select all that apply.

- Cardiac contractile strength is reduced. - Heart valves become more rigid. - Peripheral vessels lose elasticity.

Chronic stress may lead directly to cardiovascular disease because of the repeated release of which of the following?

- Catecholamines

For a patient with Risk for Imbalanced Nutrition: Less Than Body Requirements related to Impaired Swallowing, which nursing interventions are appropriate? Select all that apply.

- Check inside the mouth for pocketing of food after eating. - Keep the head of the bed elevated for 30 to 45 minutes after feeding.

What would the nurse assess for in a client with stable angina? Select all that apply.

- Chest pain relieved by rest - Chest pain caused by cigarette smoking

A 55-year-old client is upset and discussing recent losses with the nurse. Which type of losses is this client most likely experiencing based on his or her age? Select all that apply.

- Children leaving the house - Stress and job-related issues - New onset medical problems

A client presents to the emergency room passing bright red blood from the rectum. The health-care provider determines the client has bleeding hemorrhoids. Which causative factors should the nurse ask the client about? Select all that apply.

- Chronic constipation - Prolonged sitting on the job

Interventions to improve visual senses

- Clean glasses - arrange family pictures in room - offer colorful clothing - hang artwork on wall

The nurse is reviewing the medical record of a client who has not had a bowel movement for 3 days. What factors are concerning? Select all that apply.

- Client has not eaten for 48 hours. - Client is on bedrest. - Client is receiving an iron supplement. - Client is in a semiprivate room. - Client took a laxative prior to hospitalization.

Which are common postoperative complications that are preventable with consistent nursing interventions? Select all that apply.

- Clots from venous pooling of blood - Skin breakdown - Postoperative pneumonia - Incisional pain

A patient who has been immobile since sustaining injuries in a motor vehicle accident complains of constipation. The nurse encourages him to consume 8 to 10 eight-ounce glasses of fluid daily. Which fluids should the patient avoid because of the diuretic effect? Select all that apply.

- Coffee - Tea

The nurse educator is teaching a group of nurses about pain control in older adults. What should the nurse include in the presentation regarding older clients reporting pain? Select all that apply.

- Cognitive impairment can impair the ability to report pain. - Discomfort may only be evident in nonverbal signs such as grimacing.

Which structures are contained within a nephron? Select all that apply.

- Collecting duct - Bowman's capsule - Filtrating tubules

A young female client reports fatigue, feeling foggy, muscle cramps, constipation, and headaches, and states that her heart feels like it is "fluttering." During assessment, she states she has been on a high-protein, no-carb diet. Which information should the nurse give the client to educate her about the importance of eating healthy carbohydrates? Select all that apply.

- Complex carbohydrates supply energy to muscles, organs, and the brain. - Without carbohydrates, the body has to resort to using protein for energy which then cannot rebuild tissue or maintain/repair body tissue. - Healthy carbohydrates aid in the absorption of sodium and the excretion of calcium. - Healthy carbohydrates enhance insulin secretion, which is needed for cellular use of glucose.

The preoperative nurse is preparing a client for surgery. What actions will the nurse perform? Select all that apply.

- Confirm removal of dentures and contact lenses. - Confirm identification bands are correct.

The nurse is assessing a client after an abdominal surgery who speaks a different language. Which nonverbal assessment changes could indicate pain is present? Select all that apply.

- Confusion - Moaning - Irritability - Restlessness

Which of the following statements describe the nurse's general survey? Select all that apply.

- Consists of an overall impression of the patient - Assists in identifying deviations that need further exploration - Includes obtaining a full set of vital signs

The nurse is assessing the chest tube insertion site of a client with a hemothorax of the right lower lobe. Which assessment finding would most concern the nurse?

- Crepitus around the chest tube insertion site

Which are methods of nonpharmaceutical pain management? Select all that apply.

- Cutaneous therapy - Acupuncture - Application of heat and cold

The nurse is teaching his client about laxative use. What should be included in the instructions? Select all that apply.

- Daily psyllium is preferred to an over-the-counter laxative. - Do not ignore the urge to defecate. - An uninterrupted time for bowel movement should be set aside each day

A nurse is admitting a client with a myocardial infarction. Which nursing diagnosis is the highest priority?

- Decreased cardiac output

An elderly client is admitted to the hospital for treatment of heart failure. The client tells the nurse about the recent loss of his or her child and several friends in the past few years. Which findings should the nurse use to assess the client based on these multiple losses? Select all that apply.

- Decreased cognitive performance - Decreased independent functioning - Accelerated onset of physical disabilities

The nurse is caring for an elderly client who underwent joint replacement surgery. Which factors place this client at higher risk for respiratory complications postoperatively? Select all that apply.

- Decreased lung compliance - Altered forced vital capacity - Diminished diaphragmatic strength

Sensory changes that occur with aging include which of the following? Select all that apply.

- Decreased number of nerve conduction fibers results in slower reflexes. - The lens of eye becomes less flexible and less able to focus on near objects. - Taste buds atrophy and decrease in number, causing decreased ability to perceive taste.

The nurse is performing a focused bowel assessment on an older adult. Which of the following physiological changes of aging should alert the nurse to an increased risk for problems associated with bowel elimination? Select all that apply.

- Decreased sphincter control - Decreased peristalsis

Three days ago, a patient had cardiac surgery to bypass three occlusions of his coronary arteries. Veins for the bypass were harvested from his right leg. He informs the nurse that his leg is warm and tender in his right calf. The nurse notes a 3-cm periwound erythema and swelling at the distal end of the incision. Staples are intact along the incision, and there is no drainage. Vital signs are stable. The nurse would suspect that the patient has what kind of complication?

- Deep vein thrombosis

The benefits for nursing practice in using a standardized nursing language include which of the following? Select all that apply.

- Define and communicate nursing knowledge - Facilitate nursing research

Which are stages of grief as defined by Elisabeth Kübler-Ross? Select all that apply.

- Denial - Acceptance - Depression

Interventions for communicating with the visually impaired

- Describe room layout - explain unfamiliar sounds - speak before you touch the client - let the client know when you are leaving the room - introduce yourself when entering the room - call the client by name

Which are common responsibilities of the state boards of nursing? Select all that apply.

- Describing a level of competency for nursing care. - Providing approval for nursing education programs. - Funding research for nursing education. - Enforcing rules that govern nursing practice. - Developing criteria that permit someone to be licensed as a registered nurse (RN) or as a licensed practical or vocational nurse (LPN/LVN)

Each U.S. state has its own state board of nursing responsible for protecting the health, safety, and welfare of the general public. The state board of nursing meets these responsibilities by performing which of the following functions? Select all that apply.

- Determining the nurse's scope of practice - Enforcing the rules that govern nursing

The nursing student is preparing a presentation on health promotion. Which of the following activities are included in the presentation? Select all that apply.

- Developing a list of stress-management strategies - Identifying calorie counts on all food choices in restaurants

A nurse is caring for an 80-year-old patient of Chinese heritage. When planning outcomes for this patient, which actions by the nurse would meet the American Nurses Association standards for outcomes identification? Select all that apply.

- Developing culturally appropriate outcomes - Involving the patient and family in formulating the outcomes

In the communication process, which of the following best describes characteristics of an effective oral message? Select all that apply.

- Developmental level appropriate - Delivered at an appropriate time - Congruent nonverbal cues

Which are conditions that can affect sensory organs? Select all that apply.

- Diabetic retinopathy - Hypertension - Sickle cell disease

The nurse is caring for an elderly client admitted to the hospital for abdominal surgery and develops a plan of care to prevent respiratory complications. Which factors would lead the nurse to develop this plan of care? Select all that apply.

- Difficulty coughing up secretions - Diminished diaphragmatic function

Which of the following services are provided by home health agencies? Select all that apply.

- Direct care of clients in the home, performing treatments - Indirect care such as provision of medication and supplies - Respite care of clients to relieve family caregivers

The nurse caring in the intensive care unit suspects that one of her patients is experiencing sensory overload. Which findings would increase her suspicion? Select all that apply.

- Disorientation - Restlessness

The nurse educator is teaching a group of new nurses regarding hand hygiene in the perioperative area. Which factors should the nurse educator include in the session? Select all that apply.

- Do not wear fake nails - Refrain from wearing jewelry - Keep fingernails short and clean

The nurse is caring for a patient of Japanese heritage who refuses opioid pain medication despite the nurse's explaining its importance in the healing process. Which intervention(s) by the nurse is/are appropriate for this patient? Select all that apply.

- Document in the record that the patient does not want to take opioids. - Use nonpharmacological measures to help control the patient's pain.

As the family discusses with the healthcare team the possibility of removing Emma from life support, what questions should be considered before a decision is made? Select all that apply.

- Does Emma have an advance directive? - Who is the healthcare proxy? - What would Emma want?

When assisting with bedside central venous catheter (CVC) placement, which nursing intervention is appropriate? Select all that apply.

- Don sterile gloves and mask (and possibly gown). - Verify that informed consent has been obtained.

The nurse is instructing a patient about the need to replace fluid before, during, and after exercise to avoid dehydration. On what basis should she teach the patient to determine the amount of fluid to consume? Select all that apply.

- Duration of exercise - Environmental temperature

Which of the following protect(s) the body against infection? Select all that apply.

- Eating a healthy well-balanced diet - Engaging in leisure activities three times a week - Exercising for 30 minutes 5 days a week

Which are examples of beliefs? Select all that apply.

- Elderly people cannot provide a good medical history. - A person should not accept blood or blood products from another person. - Arriving 15 minutes before shift will give the appearance of dedication.

Which interventions should the nurse instruct the client to perform to decrease the incidence of urinary incontinence? Select all that apply.

- Eliminate caffeine from the diet. - Stop smoking. - Lose weight

Emma's care is transferred to hospice and the family prepares for her eventual death. What advantages would this provide? Select all that apply.

- Emma will receive holistic care. - Visitation from family and friends will be unlimited. - Support for Philip will be available. - The twins will be able to stay with their mom. - Support groups will continue after Emma dies.

The nurse educator is preparing a teaching plan on preventing urinary tract infections for a group of female college students. What information will the nurse include in the plan? Select all that apply.

- Empty the bladder soon after sexual intercourse. - Urinate when you first feel the urge to void. - Use tampons instead of sanitary napkins while menstruating.

The nurse is preparing patient teaching for a patient diagnosed with peripheral edema secondary to right-sided heart failure. What intervention will promote circulation and reduce edema in the lower extremities?

- Encourage frequent ambulation.

A 12-year-old child diagnosed with cancer is hospitalized for the first time. Considering many children in this age group possess a fear of hospitals, what strategies will the nurse use to help the child during hospitalization? Select all that apply.

- Encourage visits from outside friends - Ask the parents to bring in personal items from home

The nurse enters the client's room who is receiving oxygen at 4 L/min via nasal cannula. What should the nurse do to prevent complications? Select all that apply.

- Ensure the client keeps nasal prongs in the nares. - Assess the nares for excessive dryness. - Pad the oxygen tubing behind the ears.

The nurse is administering medications to patients using a bar-scanning device that scans the patient's identification bracelet and the medication to be administered to avoid a medication error. What types of errors does this bar-scanning device prevent? Select all that apply.

- Errors of commission - Errors in execution

A community health nurse is teaching CPR for a single rescuer of an adult victim collapse. Put the steps in order.

- Establish responsiveness. - Call 911. - Obtain an AED. - Start CPR. - Push hard and fast on the center of the chest. - When the AED arrives, turn on and apply pads. - Administer one shock per AED. - Continue CPR until help arrives.

A nurse taking care of a client who has been involved in a motor vehicle accident while intoxicated is an example of which principle?

- Ethics

Which of the following statements about race and ethnicity is/are true? Select all that apply.

- Ethnicity refers to groups whose members share a common and social heritage that is transmitted to the next generation. - Race primarily reflects biology and refers to grouping of people based on biological similarities.

A client with a nagging chronic cough has no symptoms other than shortness of breath. Upon assessment, the client mentions having a spouse who is a heavy smoker and smokes approximately two packs per day. When educating the client on the increased risk of cancer, the client quickly states, "I don't breathe in that much smoke." What information should be given to the client? Select all that apply.

- Even small amounts of smoke cause damage to the vessels and abnormal heart rate. - Secondhand smoke leads to increased risk for stroke and increased death from cancer. - There is no safe level of exposure to second hand smoke - Smoke inhalation can lead to emphysema and COPD.

A patient with heart failure has BP 120/60, HR 64, R 18, T 97.6°F, coarse crackles bilaterally, and 3+ edema to the lower extremities. An appropriate nursing diagnosis for this patient is:

- Excess Fluid Volume

Which are uses of IV therapy? Select all that apply.

- Expand intravascular volume - Correct underlying fluid or electrolyte imbalances - Compensate for an underlying problem affecting fluids and electrolytes

What actions by the nurse are best for communicating with an unconscious patient? Select all that apply.

- Explain all procedures. - Use touch appropriately. - Speak calmly and slowly. - Introduce yourself.

The nurse is caring for an older adult who is hearing impaired and cannot wear his glasses because they are broken. What interventions would be appropriate? Select all that apply.

- Explain things before performing them - speak slowly, articulating clearly - validate understanding of verbal communication - ask whether he has a "good ear"

Which of the following might be a warning sign that a child needs professional help after the death of a loved one? Select all that apply.

- Extended regression - Withdrawal from friends - Inability to sleep

Which types of loss describe loss of something tangible? Select all that apply.

- External loss - Physical loss - Loss of relationship

The nurse is caring for a client with a hypotonic fluid ordered for infusion. What would be the reason for this type of fluid being used? Select all that apply.

- Extracellular spaces are swollen. - Intracellular space is dry.

The pediatric nurse educator is preparing a teaching plan for seizure prevention for parents of children with seizures. Which of the following can trigger seizures? Select all that apply.

- Fever - Video games - Sleep deprivation - Mood-altering substances

While you are admitting an adult patient, he asks you whether he should create an advance directive. To provide him adequate information to make an informed decision, you should tell the patient which of the following? Select all that apply.

- He may change his advance directive by telling his physician or by making changes in writing. - An advance directive will ensure he gets as much or as little care as he wishes.

The nurse, working in a substance abuse rehabilitation facility, is talking with a resident who says, "I'm just here to avoid going to jail. I'm not addicted to alcohol. I just enjoy it, but I'm going to quit to avoid getting arrested again." Which of Pender's Health Promotion Model assumptions is this resident demonstrating? Select all that apply.

- Health professionals are part of the person's interpersonal environment. - The person values positive growth and attempts to balance change and stability. - The person seeks to actively regulate his own behavior

The hospital nurse educator is preparing an orientation class for those newly hired on the surgical suite. Which of the following will the educator include in the orientation curriculum regarding hand and fingernail care? Select all that apply.

- Healthcare staff must routinely inspect their hands for breaks in skin. - Healthcare staff are to avoid wearing nail polish at all times.

Before a client is taken to the OR area, which items should be removed and given to the family or secured? Select all that apply.

- Hearing aid - Glasses - Jewelry

The nurse administers a beta-adrenergic agent to a patient with congestive heart failure. What assessment findings would indicate the drug was working?

- Heart rate changes from 92 beats/min to 76 beats/min.

The nurse is preparing for heat and cold application. Which of the following statements are true? Select all that apply.

- Heat/cold devices can cause superficial tissue damage. - Heat/cold devices should never come in direct contact with the skin. - Heat/cold devices should be used intermittently.

The nurse practitioner is performing an annual physical examination on an 86-year-old female. What assessments are most important for the nurse to include in her examination? Select all that apply.

- Height and weight - Gait and balance

A nurse on a medical-surgical unit asks a licensed practical nurse (LPN) to help with nutritional assessments for newly admitted patients. What part of the nutritional assessment can be delegated to the LPN? Select all that apply.

- Height and weight - Intake and output - Nutritional history

The home health nurse learns that an elderly patient isn't able to get to the grocery store. She doesn't have much food in her home, and eats and drinks little. Most of her time is spent sitting in her chair watching television, often not realizing that she has bladder leakage. Which nursing actions would she implement to reduce the risk of developing a pressure ulcer? Select all that apply.

- Help her to get out of the chair every 2 hours. - Change her clothing frequently. - Encourage her to wear incontinence products.

Elenore is an older adult who lives alone and has fallen and fractured her hip. She cannot get to the phone to call for help. Her pain worsens as time passes and she becomes confused as she waits for someone to find her. What factors are exacerbating the situation? Select all that apply.

- Helplessness - Fear - Cognitive impairment

A client with terminal cancer is in the last few hours of life and agitated. Which factors can cause agitation in this client? Select all that apply.

- Hepatic failure - Cerebral hypoxia - Medication side effects

Dr. Elisabeth Kübler-Ross has written extensively on the psychological stages of death and dying. Which statement(s) listed below are most consistent with her theory? Select all that apply.

- Her theory has expanded and can now be applied to losses other than death. - Patients may experience two or three stages at the same time.

What clinical manifestations might a nurse expect to see if a client has impaired renal function? Select all that apply.

- High blood pressure - Altered mental status - Fluid retention

The nurse performs a routine assessment on Mr. Martin and discovers that his pulse oximetry reading is 89%. She contacts the healthcare provider and receives an order for oxygen at 2 L/nasal cannula. What hazards should be considered with the use of oxygen? Select all that apply.

- High oxygen concentration can lead to alveolar collapse. - Toxicity can develop if too much oxygen is delivered. - Oxygen tanks are pressurized and can turn into an unguided missile. - Oxygen is highly combustible.

Which expectations are covered by the American Hospital Association Patient Care Partnership? Select all that apply.

- High-quality care - Involvement in care - A clean and safe environment

Philip and Emma are a young married couple expecting twins. They have spent years trying to conceive and were finally able to do so with artificial insemination. Both babies, a boy and a girl, were born small but healthy. The night after delivery, Emma suffers a significant brain hemorrhage and is placed on life support. In the next few days, her family is told she is brain dead and only being kept alive by the machines. They are asked to consider withdrawing life support, allowing her to die. What factors will impact Philip's grieving process? Select all that apply.

- His attachment to his wife - Support of family and friends - Previous experiences with loss - Spiritual beliefs

The nurse is administering the 0900 dose of heparin 5,000 units subcutaneously ordered every 6 hours to a patient with deep vein thrombosis (DVT). At 0800, the patient's laboratory values show partial thromboplastin time (PTT) and clotting times are four times the normal range. The nurse observes petechiae on the patient's buttocks and back and recognizes these as signs of risk for significant bleeding. The correct nursing actions at this time are below. Select all that apply.

- Hold the medication dose at this time. - Chart the reason the medication was not given. - Assess for other significant signs and symptoms. - Record abnormal findings in the patient's health record.

Home healthcare and home hospice care are two different types of home health services. What are the differences between these services? Select all that apply.

- Home healthcare promotes independence in clients; home hospice care promotes comfort and quality of life. - Home hospice care is focused on managing symptoms; home healthcare is focused on fostering independence.

What impacts fluid balance in the body? Select all that apply.

- Hormone levels - Fluid intake - Kidney function - Nutritional status

Which aspects of healthcare are affected by a client's culture? Select all that apply.

- How the client views healthcare - How the client views illness - The types of treatments the client will accept - When the client will seek healthcare services

Which of the following best describe the primary goal(s) of evidence-based practice? Select all that apply.

- Identify the most effective treatments for disease processes, conditions, or problems - Identify the most cost-effective treatments for disease processes, conditions, or problems

Which of the following statements describes legal responsibilities after the death of a person? Select all that apply.

- If the patient is donating organs, necessary arrangements must be made. - The person who pronounces death must sign the death certificate.

Which of the following is a primary intervention? Select all that apply.

- Immunization for meningitis of college-bound students - Safer sex education for high school students - Lobbying for health education in the schools

The nurse understands that which of the following organizational factors have been shown to contribute to errors and safety problems in healthcare? Select all that apply.

- Inadequate training of personnel - Inadequate staffing in the organization - Staff reluctance to speak up about risks and errors

A nurse is developing a care plan for a client at risk for pneumonia after surgery. Which actions should be included? Select all that apply.

- Incentive spirometer every 1 to 2 hours while awake - Early ambulation - Oral intake of 3 L/day

A client reports that he follows a strict vegetarian diet. What recommendations should the nurse give? Select all that apply.

- Increase intake of food fortified with vitamin B12 and B12 supplements. - Sun exposure can help compensate for lack of dietary vitamin D. - Eat foods containing vitamin C to improve iron absorption.

The patient was admitted to the ICU in respiratory acidosis secondary to smoke inhalation and exposure to caustic gases. After placement of an endotracheal tube and connection to a mechanical ventilator, the arterial blood gas results are pH = 7.28, PaO2 = 85, PaCO2 = 60. What changes to care does the nurse anticipate?

- Increase the number of breaths per minute on the ventilator.

An individual has recently moved from the coast of Florida to the Rocky Mountains in Colorado. What can be expected to physiologically occur over time to help facilitate oxygenation? Select all that apply.

- Increased RBC production - Increased lung volume and pulmonary vasculature - Increased ventilation - Arterial chemoreceptors stimulate ventilation

The nurse is educating a group of teenagers about the physical damage that occurs from tobacco smoke. What should the nurse include in the teaching session? Select all that apply.

- Increases mucus production - Causes bronchial inflammation - Leads to lung cancer - Paralyzes cilia

According to Pender's Health Promotion Model, which variables must be considered when planning a health promotion program for a client? Select all that apply.

- Individual characteristics and experiences - Behavioral outcomes - Behavior-specific cognition and affect

Which of the following nursing diagnosis statements, using the three-part format (PES), are correct? Select all that apply.

- Ineffective airway clearance related to excessive mucus AMB cough, shortness of breath, change in respiratory rate and rhythm - Caregiver role strain related to increasing care needs AMB wife states, "He is just getting too heavy for me to lift"

The nurse is caring for a 6-month-old infant diagnosed with RSV, a viral infection causing copious airway secretions. What consideration will influence the nurse's plan of care most?

- Infants' airways are narrower and more easily obstructed.

Why is an accurate description of the location of a wound important? Select all that apply.

- Influences the rate of healing - Determines the appropriate treatment choice - Affects patient movement and mobility

The preoperative nurse is preparing a patient for surgery. Identify the interventions the nurse will perform. Select all that apply.

- Inform the family to wait in the surgical waiting room. - Remove the patient's dentures and contact lenses.

The nurse is visiting a client who resides in a single-room occupancy hotel. Groups of people are leaning against the building and smoking on the steps. There is obvious substance abuse occurring in the lobby and halls of the building. There is no running water in the room, and the bathroom down the hall is in disrepair and filthy. A primary concern that the nurse must consider when making this visit is safety. Which of the following actions are appropriate safety measures? Select all that apply.

- Inform the home health agency of the nurse's route and time of visit. - Do not visit if the nurse senses danger when he arrives at the site.

The nurse is caring for a patient with reduced perfusion to the extremities. The nurse evaluates the patient and finds the response to therapy is not optimal. What lifestyle change does the nurse suspect is contributing to the lack of response?

- Ingesting 1,500 mL of fluid per day

A new nurse is learning how to set up telemetry monitoring for a new admission. Put the steps in the correct order.

- Insert a new battery into the transmitter. - Turn on the transmitter. - Connect the lead wires to the transmitter. - Expose the client's chest and shave the hair if dense. - Clean the client's skin with an alcohol pad. - Remove the electrode backing. - Attach the lead wires to the electrodes. - Apply the electrodes to the sites. - Secure the monitoring equipment. - Place the transmitter in the pouch and the pouch strings around the client's neck.

The nurse is developing a plan of care for a client with a chest tube. Which intervention should the nurse do first if the chest tube becomes dislodged from the drainage container?

- Insert the tube into sterile water.

The nurse is caring for a patient with metabolic acidosis secondary to renal failure caused by poor glucose regulation. The patient reports a headache, weakness, and nausea. The nurse assesses an elevated blood sugar, Kussmaul breathing, and peripheral vasodilation. What collaborative interventions will the nurse anticipate to restore pH balance? Select all that apply.

- Insulin to lower blood sugar - Dialysis to remove toxins - Bicarbonate administration

The nurse is developing a plan of care for a client with fluid losses related to nasogastric drainage. Which goals would be most appropriate to set for this client? Select all that apply.

- Intake and output will be balanced in 48 hours. - Acid-base balance will be achieved in 48 hours. - Serum electrolytes will be normal within 48 hours.

The nurse is caring for a 65-year-old client with a compression fracture of the spine with decreased mobility as well as intractable pain. The nurse requests a prescription for TED hose. The health-care provider prescribes TED hose and aspirin 81 mg PO QD. Which factors indicate the need for the TED hose and the aspirin? Select all that apply.

- Intractable pain - Decreased mobility

The nurse is tallying the intake and output record for the shift. What should be included on the intake record? Select all that apply.

- Intravenous fluids - Hot tea - Ice chips - Ice cream

A patient has a history of chronic constipation. Which of the following medications prescribed for the patient would alert the nurse to be especially vigilant in observing for constipation and teach the client about preventive measures? Select all that apply.

- Iron - Pain medications

According to the Uniform Determination of Death Act of 1981, which factors must be present to declare an individual dead? Select all that apply.

- Irreversible cessation of cardiac functions - Permanent cessation of all brain functions - Permanent ending of respiratory functions

A 75-year-old patient is tearful, shaky, and withdrawn. She tells you that she is "worrying herself to death" about losing her aging husband and being "all alone." Why do you recognize this reaction as Anxiety rather than Fear? Select all that apply.

- It concerns future or anticipated events. - It concerns anticipation of danger rather than a present danger. - There is a psychological rather than a physical threat.

The nurse is performing a vision examination. In assessing for color blindness, the nurse applies which knowledge? Select all that apply.

- It may be genetically inherited. - It is more common in males. - It may be the result of macular degeneration.

The nurse is conducting an assessment while admitting a female Chinese patient to the medical unit. Which of the following actions will best enhance communication between the nurse and patient during the assessment? Select all that apply.

- Keeping 18 inches to 4 feet between nurse and the patient - Assessing for any language barrier

The nurse on a medical unit notes a moderate amount of fluid accumulation in the feet and ankles of a 75-year-old patient. The nurse will further assess this patient for indications of which conditions? Select all that apply.

- Kidney disease - Heart failure

The nurse is educating a group of older adults about ways to decrease the risk of developing a fecal impaction. Which risk factors should the nurse include in the session? Select all that apply.

- Laxative overuse - Diminished fluid intake - Decreased ability to exercise

The nurse is educating a client regarding the cardiovascular effects of chronic alcohol abuse. Which information should the nurse include? Select all that apply.

- Leads to congestive heart failure - Forms thrombi in the coronary arteries - Depresses cardiovascular centers of the brain

Which are urinary symptoms that may occur as a result of the aging process? Select all that apply.

- Leakage of urine - Nocturnal frequency of urine - Bladder infections

Which action by the nurse breaches patient confidentiality? Select all that apply.

- Leaving patient data displayed on a computer screen where others may view it - Remaining logged on to the computer system after documenting patient care

A nurse is caring for a patient with a peripheral IV line located in the right forearm. The patient informs the nurse that the IV site is burning. Upon assessment the nurse determines that the IV solution has infiltrated. What site(s) is/are appropriate to consider when restarting the IV line? Select all that apply.

- Left hand - Right antecubital area

The nurse is giving you the shift report. She states the client's diagnoses, treatments, and course of hospitalization. When describing the client she states, "Whenever I try to teach him something, he becomes difficult and argumentative." What client information about patient teaching should you ask? Select all that apply.

- Level of literacy - Primary language - Level of anxiety - Questions answered

For a patient to be eligible for insurance benefits covering hospice care, a physician must certify which of the following? Select all that apply.

- Life expectancy is not more than 6 months. - The condition is not expected to improve.

Which areas of the brain are stimulated by the hypothalamus when a person experiences pain? Select all that apply.

- Limbic system - Frontal cortex - Somatosensory cortex

Dietary Guidelines for Americans

- Limit intake of sugar, salt and alcohol - Limit the consumption of saturated fats - Recommend choosing fiber-rich foods - Meet USDA food guideline recommendations - Recommend achieving and maintaining healthy weight.

Which dietary changes should the nurse instruct a client with hypertension to make to control electrolyte and fluid balance? Select all that apply.

- Limit sodium intake. - Increase calcium intake. - Increase potassium consumption.

Which diagnostic tests would the nurse expect the health-care provider to prescribe to determine a client's risk for cardiovascular disease? Select all that apply.

- Lipid panel - Cholesterol level - C-reactive protein

Which factors affect the perception of a stimulus? Select all that apply.

- Location of the receptors - Number of receptors activated - Frequency of action potentials generated - Changes in frequency, location, and number of stimuli

The nurse suspects that an older adult patient may have difficulty hearing. What strategies will the nurse use in communicating with this patient until he is certain that there is hearing loss? Select all that apply.

- Look directly at the patient when speaking - Speak more slowly than usual - Allow some extra time for the patient to respond

The nurse is teaching bowel health to a group of senior citizens. What are some common reasons for bowel changes in the older adult? Select all that apply.

- Loss of smooth muscle toneWeakened abdominal muscles - Immobility - Weakened abdominal muscle

Obesity is associated with higher risk for which of the following conditions that affect the pulmonary and cardiovascular systems? Select all that apply.

- Lower respiratory tract infections - Sleep apnea - Hypertension

The parents of an adolescent client ask about strategies that can be used to aid in obesity prevention. Which strategies should the nurse present to them? Select all that apply.

- Maintain a well balanced diet but eat smaller portions. - Teach the adolescent how to healthier snacks. - Try to have 30 minutes of outdoor activity every day.

Which of the following is/are an appropriate goal(s) for a patient with urinary incontinence? Select all that apply.

- Maintain daily oral fluids to 8 to 10 glasses per day. - Limit daily caffeine intake to less than 100 mg.

The home health nurse is developing a plan of care for her 76-year-old patient. What are the primary nursing goals the nurse will include in her plan? Select all that apply.

- Maintain the patient's independent functioning as much and for as long as possible - Teach the patient and caregivers how and when to call for professional help - Arrange for appropriate care that is needed in the home

Which of the following task(s) may be delegated to a certified nursing assistant (CNA)? Select all that apply.

- Measuring and recording intake and output - Performing a bedside dipstick urine test - Applying a condom catheter to a male patient

Which are examples of types of receptors in the body? Select all that apply.

- Mechanoreceptors - Photoreceptors - Chemoreceptors

An impoverished 55-year-old client has accrued a large hospital charge after emergency surgery and is unable to pay the bill. What insurance can the nurse recommend to the client to help with the cost? Select all that apply.

- Medicaid - A charitable organization

Which family function(s) is/are outlined in the structural-functional family theory? Select all that apply.

- Meeting the emotional needs of family members - Being productive members of society

The student nurse observes the staff nurse providing care to a patient with a chest tube. Which of the nurse's actions should the student recognize as incorrect and report to the nursing instructor?

- Milking the chest tube to promote drainage

Which actions can the nurse take to prevent sensory overload? Select all that apply.

- Minimize ambient light in the patient's room. - Plan care to provide periods of sleep. - Speak with a moderate tone of voice. - Restrict caffeine intake during hospitalization.

The nurse is caring for a confused client who is becoming more agitated. Which actions could should the nurse take? Select all that apply.

- Minimize unnecessary light in the client's room. - Plan care to provide uninterrupted periods of sleep. - Speak calmly in a moderate tone.

Identify the appropriate interventions for a patient with hypovolemia. Select all that apply.

- Monitor I&O daily. - Encourage fluid intake. - Monitor electrolyte balance.

A client is prescribed the opioid morphine sulfate for postoperative pain. Which action should the nurse take before administering the medication? Select all that apply.

- Monitor the patient's respiratory status. - Assess the pain score.

The nurse is caring for a client who had a colon resection for removal of a cancerous tumor. On the surgical unit, which postoperative actions are important for complication prevention? Select all that apply.

- Monitor vital signs regularly. - Assist the patient to turn, breathe deeply, and cough every 2 hours. - Assess the drainage from the surgical site.

Clients at risk for hypovolemia:

- Motor vehicle accident with trauma - Uterine rupture during childbirth - Vomiting from a viral infection - Significant burns to the body - Hiker without water supply

Which findings related to circulation would the nurse expect to find in a client within hours to days of death? Select all that apply.

- Mottling of the extremities - Decreased blood pressure - Diminished urinary output

The basal metabolic rate is impacted by which factors? Select all that apply.

- Muscle mass - Body temperature - Environmental temperature - Disease process

A 74-year-old client is hospitalized with acute onset delirium of unknown etiology. The nurse questions the family and asks what has changed recently. Which responses made by the family could have contributed to the delirium? Select all that apply.

- New medication - Electrolyte imbalance - Urinary tract infection

The nurse is speaking with her neighbor about the gout pain in his feet. What recommendations could be made for dealing with his chronic pain? Select all that apply.

- Nonsteroidal anti-inflammatory medications - Relaxation techniques - Massage

A patient has a history of COPD. His pulse oximetry reading is 97%. What other findings would indicate adequate tissue and organ oxygenation? Select all that apply.

- Normal urine output - Strong peripheral pulses - Normal muscle strength

A nurse notes a history of peripheral neuropathy in the medical record of a client. What should the nurse include in the assessment of this client? Select all that apply.

- Numbness of the feet - Feelings of pins and needles - Itching on the soles of feet

Under the American Nurses Association (ANA) Code of Ethics, the nurse has the professional responsibility to uphold ethical behavior. Choose the statements below that are accurate about the Code of Ethics. Select all that apply.

- Nurse actions are to be at the level expected by the profession. - Nurses are professionally bound to give correct information to the patient.

A nurse with a large caseload of patients needs to delegate some assessment tasks to other members of the health team. The nurse is unsure which tasks can be delegated to nursing assistive personnel (NAP) and which are appropriate for a licensed practical nurse (LPN) or a registered nurse (RN). To which sources should the nurse turn find out to whom to delegate which tasks? Select all that apply.

- Nurse practice act of his state - ANA Scope and Standards of Practice

The American Nurses Association (ANA) lists recommendations concerning DNARs and ANDs. Which of the following statements are consistent with the ANA recommendations? Select all that apply.

- Nurses should take an active role in developing policies related to DNARs and ANDs. - If there is any conflict or confusion regarding a DNAR or AND, the competent patient's choices will always have the highest priority.

To reflect the changes in healthcare and nurses' expanded roles, the International Council of Nurses revised the definition of nursing. Which statements are consistent with the revised definition of nursing?

- Nursing encompasses the autonomous and collaborative care of others. - Nursing includes the care of ill, disabled, and dying people. - Participation in shaping health policy is a nursing role.

According to the American Nurses Association (ANA), which statements best describe the characteristics of registered nursing? Select all that apply.

- Nursing practice is individualized. - Caring is central to the practice of the registered nurse. - Nurses coordinate care by establishing partnerships.

Which characteristics of registered nursing are identified by the American Nurses Association (ANA)? Select all that apply

- Nursing practice is individualized. - Nurses coordinate care by establishing partnerships.

Which of the following statement(s) best describe(s) nursing research? Select all that apply.

- Nursing research is a systematic, objective process of analyzing phenomena important to nursing. - The purpose of nursing research is to develop knowledge about issues important to nursing.

Philip's mom convinces him to seek assistance from his family practitioner for his behavior changes. What should the nurse include in the assessment of grief and loss? Select all that apply.

- Nutritional intake and weight - Emotional feelings of helplessness and depression - Behaviors of forgetfulness and crying - Changes in sleep patterns

The nurse is preparing a young adult, female patient for intravenous pyelogram (IVP). What are the priority actions by the nurse prior to this procedure? Select all that apply.

- Obtain an informed consent prior to the procedure. - Ask whether the patient has an allergy to shellfish. - Check laboratory results for serum BUN and creatinine. - Determine whether the patient has had a barium enema in the past 4 days.

The nursing instructor is teaching students how to use a fracture pan for patients who are unable to move or turn independently. What are the most appropriate instructions for this procedure? Select all that apply.

- Obtain help from another healthcare worker. - Place the wide, rounded end of the pan toward the front of the patient. - Assist the patient to a side-lying position prior to placing the bedpan.

Which of the following tasks may be delegated to a certified nursing assistant (CNA)? Select all that apply.

- Obtaining vital signs every 15 minutes after a seizure - Padding the sides of a bed for seizure precautions

Which of the following statements are true of common neurological changes in older adults? Select all that apply.

- Older adults have a slower reaction and a decreased ability for rapid problem-solving. - With advanced age, the number of functioning neurons decreases. - Neurological deficits may be attributed to medications or medication interactions.

At which times should the nurse assess pain levels on a client in the hospital? Select all that apply.

- On admission - With vital signs - Prior to procedures - After giving pain medication

For which patient(s) should the nurse avoid using back massage? Select all that apply.

- One who underwent heart surgery 3 days ago - One who sustained rib fractures from a fall

The nurse caring for a postsurgical patient obtains an oral temperature reading of 103°F. She contacts the surgeon, obtains an order, and administers acetaminophen 650 mg orally. Which clinical information should the nurse document? Select all that apply.

- Oral temperature reading of 102°F - The call to the surgeon to obtain the order - Administering acetaminophen 650 mg orally

The nurse admits a patient diagnosed with pneumonia. Which data findings indicate that the patient is not oxygenating adequately? Select all that apply.

- Oxygen saturation 87% - Respiratory rate 52 breaths/min - Cyanosis of the nailbeds and lips

The nurse is teaching a patient about the importance of reducing saturated fats in his diet. The nurse will recognize that learning has occurred if, upon questioning, the patient replies that he should read product labels to eliminate the intake of which saturated fats? Select all that apply.

- Palm oil - Coconut oil

A client has just voided 50 mL, yet reports that his bladder still feels full. The nurse's next actions should include which of the following? Select all that apply.

- Palpating the bladder height - Performing a bladder scan - Asking the patient about his recent voiding history

Which of the following are examples of high-quality nursing documentation? Select all that apply.

- Patient states, "When I get up in the morning, I feel dizzy." - Patient is alert and oriented to person, place, time, and surroundings. - Patent has no complaints of pain at this time.

The nurse working in an ambulatory care program asks questions about the client's locus of control as a part of his assessment because of which of the following? Select all that apply.

- People who feel in charge of their own health are the easiest to motivate toward change. - People who feel powerless about preventing illness are least likely to engage in health promotion activities. - People who respond to direction from respected authorities often prefer a health promotion program supervised by a health provider.

The nurse is admitting to the medical-surgical unit an older adult woman with a diagnosis of pulmonary hypertension and right-sided heart failure. The patient is complaining of shortness of breath, and the nurse observes conversational dyspnea. What is the first action the nurse should take?

- Perform a quick physical examination of breathing, circulation, and oxygenation.

The nurse is developing a plan of care for a client with a surgical incision. Which interventions should the nurse include to decrease the client's risk for infection? Select all that apply.

- Perform meticulous hand hygiene - Assess incisions, drains, and drainage - Monitor vital signs and observe trends

Which electrolytes would be found in the intracellular fluid? Select all that apply.

- Phosphate - Potassium - Magnesium

The nurse is using an EHR system. Which feature does not improve the safety of patient care delivered by the nurse?

- Physician order entry - Decision support tools - Elimination of poor handwriting - Improved accessibility

Which finding would the nurse expect when assessing a client with pulmonary edema?

- Pink and frothy sputum

Which actions assist the nurse in orienting a confused client to time, place, person, or situation? Select all that apply.

- Place a clock in the client's room. - Wear a readable name tag. - Maintain a clean, uncluttered environment.

A patient with tuberculosis is scheduled for computed tomography (CT). How should the nurse proceed? Select all that apply.

- Place a surgical mask on the patient and transport him to CT lab. - Notify the computed tomography department about precautions prior to transport.

While a patient is receiving hygiene care, her chest tube becomes disconnected from the water-seal chest drainage unit (CDU). Which action should the nurse take immediately?

- Place the disconnected end nearest the patient into a bottle of sterile water.

A nurse is assessing a client with cardiac pain. What is the difference between cardiac pain and pleuritic pain? Select all that apply.

- Pleuritic pain is unrelieved with nitrates. - Cardiac pain includes radiation to the left arm, nausea, dyspnea, fatigue, and anxiety. - Cardiac pain typically does not change with inhalation or exhalation.

Health promotion activities for all older adults include teaching and facilitating which of the following immunizations? Select all that apply.

- Pneumonia - Influenza - Varicella

The nurse logs on to the electronic health record to enter the admission orders for a patient seen in the physician's office. However, when attempting to retrieve the patient's health history, the nurse keeps getting error messages. What is the likely problem?

- Poor interoperability - Lack of connectivity - Improperly transmitted information - Network failure - Incorrect password

The nurse admits a patient to the surgical unit from the postanesthesia care unit. The patient has an oral airway in place and awakens only to painful stimuli. What is the priority nursing action?

- Position the patient with the head turned to the side.

The nurse is caring for a Native American in a rural rehabilitation facility. The nurse notices that the patient has eaten very little since his admission 10 days ago. When she asks the patient about his eating, he states, "I can't eat any of this food. It just isn't what I eat at home and we don't prepare our foods this way." The nurse explains that the patient is on a very specific cardiac diet as a result of his heart attack and that he has lost 7 pounds since admission. Based on this scenario, what is/are the most appropriate nursing diagnosis(es) for this patient? Select all that apply.

- Possible Knowledge deficit related to disease process - Imbalanced nutrition: less than body requirement related to cultural dietary practices

The nurse working on a surgical stepdown unit receives a report from the perioperative nurse about a new client who will be admitted after undergoing a colectomy with a formation of an ileostomy. What information should the nurse obtain from the perioperative nurse? Select all that apply.

- Postoperative vital signs - Presence of drains and tubes - Location and type of intravenous lines

Which factors place female clients at higher risk for urinary tract infections? Select all that apply.

- Pregnancy - Menopause - Sexual activity

Which of the following populations are considered high risk for the development of hemorrhoids? Select all that apply.

- Pregnant women - School bus drivers

Which phases of surgical care are part of perioperative nursing care? Select all that apply.

- Preoperative - Intraoperative - Postoperative

What should the nurse include in the assessment of a client admitted with a diagnosis of community-acquired pneumonia? Select all that apply.

- Presence of cough - Amount and color of sputum - Occurrence of fever

The perioperative nurse maintains the safety of the patient during surgery with which of the following goals? Select all that apply.

- Preventing infection - Improving the accuracy of patient identification - Preventing mistakes in surgery

The nurse is providing tuberculin testing at a campus health program. Which factors should the nurse assess for when developing a prevaccination screening tool? Select all that apply.

- Prior exposure to tuberculosis - Country of birth and recent travel - Employment in a health-care setting

Which of the following are main functions of a computer? Select all that apply.

- Process - Storage - Output

The nurse analyzes the patient's ECG and compares it with a baseline ECG recorded before the patient began having chest pain. What finding indicates a problem with the ventricle?

- Prolonged QRS segment

Which are the purposes of the Health Insurance Portability and Accountability Act of 1996? Select all that apply.

- Protect health insurance benefits for workers who change jobs. - Establish standards to protect client privacy and confidentiality. - Protect coverage for individuals with preexisting conditions.

Which are functions of body fat? Select all that apply.

- Protection of vital organs - Essential to cell metabolism - Enables nerve-impulse transmission

Which interventions should the nurse include when managing pain in a client? Select all that apply.

- Provide a back rub. - Reposition the client. - Determine the effectiveness of pain medication.

You are caring for an adult patient with a tracheostomy who is being mechanically ventilated. His pulse oximetry reading is 85%, heart rate is 113 beats/min, and respiratory rate is 30 breaths/min. The patient is very restless. His respirations are labored, and you hear gurgling sounds. You auscultate crackles and rhonchi in both lungs. What is the most appropriate action to take?

- Provide endotracheal suctioning.

Which nursing interventions are appropriate for a 38-year-old patient admitted with a diagnosis of Dehydration who has a temperature of 101.5°F (38.6°C)? Select all that apply.

- Provide oral and/or IV fluids. - Take vital signs every 2 hours.

A patient has just had a chest tube inserted to dry-seal suction drainage. Which of the following is a correct nursing intervention for maintenance?

- Provide the patient with a paper and pencil or letter board.

Which intervention is appropriate for a client receiving palliative care? Select all that apply.

- Providing moisturizing eyedrops to an unconscious patient whose eyes are dry - Administering a medication to relieve the nausea of a patient with end-stage leukemia

The nurse is preparing to administer otic medications to her 35-year-old patient. What are the most appropriate actions by the nurse? Select all that apply.

- Pull the pinna up and back. - Place patient in side-lying position with appropriate ear up.

Eldon Martin is a 75-year-old retired Marine Corps officer. He smoked cigarettes most of his adult life, but quit 10 years ago when he learned he had allergy-induced asthmatic lung disease. He comes to the hospital today with a high fever, productive cough, and pain in his chest. He is diagnosed with pneumonia.What additional assessment findings would be important for the nurse to gather in relation to oxygenation concerns? Select all that apply.

- Pulse oximetry reading - Arterial blood gas - Lung sounds - Number of years of smoking

The nurse obtains vital signs for a 56-year-old patient who underwent surgery yesterday. Which finding(s) require(s) further assessment? Select all that apply.

- Pulse rate 118 beats/min - Respiratory rate 35 breaths/min

Which of the following interventions would be appropriate for a client who has a fever? Select all that apply.

- Put an ice pack on the client's neck and axillae. - Offer the client fluids to drink every 1 to 2 hours.

Which are the main premises of hospice care? Select all that apply.

- Quality of life is as important as the length of life. - Those who are terminally ill should be allowed to face death with dignity surrounded by family and loved ones.

A nurse is explaining the benefits of hospice services to a client with end-stage chronic obstructive pulmonary disease. Which statements best explain hospice? Select all that apply.

- Quality of life is more important than length of life. - Clients have the right to die with dignity - Clients should be surrounded by family when they are dying. - Hospice services are provided for clients with six months or less life expectancy

Which signs of infection should the nurse instruct the client to report to the health-care provider? Select all that apply.

- Redness at the incision site - Drainage from the incision - Temperature over 100.5 F

The Centers for Disease Control and Prevention (CDC) is a federal agency devoted to infection control and prevention in healthcare settings. What are the goals of the CDC? Select all that apply.

- Reduce catheter-associated adverse events (infections) by 50% - Reduce targeted antimicrobial-resistant bacterial infections by 50%

Interventions for decreasing sensory overload

- Reduce noxious odors promptly - minimize lighting - minimize nighttime interruptions - only use the television when the client is interested - lower voice and alarm sounds

Which instructions are most important for the nurse to provide a client when using portable oxygen tanks in the home setting?

- Refrain from any smoking in the home. - Store oxygen tanks in an upright position.

What is/are the primary roles of the Food and Drug Administration (FDA)? Select all that apply.

- Regulate the testing, manufacture, and sale of all medications - Monitor safety and effectiveness of medications available to consumers

While working with a certified nursing assistant (CNA) in a local nursing home, the nurse knows that which of the following fall risk and prevention measures may be delegated to the CNA? Select all that apply.

- Remove clutter and spills in patient rooms. - Place nonskid slippers on all patients. - Answer call lights in a timely manner.

The home health nurse just removed an indwelling urinary catheter from a client per the health-care provider's order. Which instructions should the nurse provide the client? Select all that apply.

- Report any pain or burning upon urination. - Increase oral fluid intake to promote urine production. - Contact the health-care provider if unable to urinate 8 hours after catheter removal.

Which of the following is an example of whistleblowing? Select all that apply.

- Reporting fraudulent billing practices - Reporting unsafe work practices - Reporting a coworker for working under the influence of drugs

A postoperative client informs the nurse of a pain level of 7 on a scale of 1 to 10 at the abdominal surgical incision site. Which interventions should the nurse provide to alleviate the pain? Select all that apply.

- Reposition the client - Administer pain medications as prescribed - Instruct on use of progressive muscle relaxation

A nurse is reviewing the ECG complex of a client post myocardial infarction (MI). What is the QRS complex?

- Represents ventricular depolarization and leads to ventricular contraction

When the carbonic acid portion of the buffering system is out of balance, which of the following occurs? Select all that apply.

- Respiratory Alkalosis - Respiratory Acidosis

The nurse administers intravenous morphine sulfate to a patient for pain control. She will need to monitor her patient for which of the following adverse effects?

- Respiratory depression

Identify the mechanisms involved in acid-base balance. Select all that apply.

- Respiratory mechanisms - Renal mechanisms - Buffer systems

What are the roles of the circulating nurse? Select all that apply.

- Respond to emergencies - Attends to client during anesthesia induction - Communicates with family and staff outside operating room

Caring is a central concept in nursing that involves which of the following? Select all that apply.

- Responding compassionately to client needs - Acting in ways to preserve human dignity - Connecting with others to give and receive help - Using active listening

The nurse has been assigned to a caseload of home health clients. Before making home visits, which two planning activities must she perform first?

- Review the cases to determine the reasons for the visits. - Contact the clients to arrange for the visits.

Which factors should the perioperative nurse assess when caring for an older client undergoing surgery? Select all that apply.

- Risk for infection - Impaired renal function - Impaired wound healing

The nurse is developing a plan of care for a client who just had a chest tube inserted. Which emergency supplies should the nurse keep at the client's bedside? Select all that apply.

- Rubber-tipped clamps - Spare disposable drainage system - Petroleum gauze

The nurse is teaching nutrition counseling to a client with cholecystitis and discussing the need to avoid fatty foods. What foods should be avoided? Select all that apply.

- Salmon - Avocado

Identify the nurse who is acting as a community health nurse. Select all that apply.

- School nurse who provides screening and direct care in the elementary school - Parish nurse who offers health education after services each Sunday - Nurse who works for the Red Cross by providing disaster relief - A nurse administering vaccines to inmates in a correctional facility

Which of the following are examples of invasion of privacy by nurses? Select all that apply.

- Searching a patient's belongings without permission - Reviewing the plan for patient care in the lunchroom - Releasing patient health information to local newspaper reporters

Which factors can impact a person's sensory alteration? Select all that apply.

- Sensory deprivation - Sensory overload - Sensory deficit

Risk factors for urinary tract infection

- Sexual intercourse for women - Diabetes - Kidney Stones - Enlarged prostate - Pregnancy

Which questions are examples of bioethics considerations? Select all that apply.

- Should a client be allowed to die? - Should a nurse question an order? - Should a client be told about a medical error?

Which interventions should the nurse incorporate into the plan of care for a client with a new ostomy that is having difficulty coping with the body change? Select all that apply.

- Show acceptance when working with the stoma. - Explain to the client that his or her sexual relations would not change. - Provide information regarding support groups available for clients with ostomies. - Allow the client to ventilate feelings about having a new colostomy and how it changes his or her life.

The nurse is completing the preoperative checklist. What items will be addressed? Select all that apply.

- Signed consent forms - Medical history - Completed preoperative orders - Verification of identity information

A 73-year-old client admitted after a stroke has expressive aphasia. Which pain intensity scales would be appropriate to use with this client? Select all that apply.

- Simple descriptor scale - Visual analog scale - Wong-Baker FACES

As a nurse working in a bariatric clinic, you are conducting a presurgery assessment for a 24-year-old client. Which anthropometric measurements should be taken? Select all that apply.

- Skinfold measurements - Hydrodensitometry - Abdominal circumference - Waist-to-hip ratio - Body mass index

What statements best describe the association between smoking and pulmonary infections? Select all that apply.

- Smoking interferes with respiratory functions, including the ability to move the chest, cough, and sneeze. - Smoking decreases movement of the cilia in the lower airways, creating a favorable environment for bacterial growth.

Risk factors for physical abuse of older adults include which of the following? Select all that apply.

- Socioeconomic status below the poverty level - Residence in low-income housing - Impairment of the older adult

Which are functions of water in the body? Select all that apply.

- Solvent - Lubricant - Body structure and form

Which of the following patients would you expect to be at risk for decreased activity? Select all that apply.

- Someone living in a skilled nursing facility - Healthy adult who works as a computer programmer - Obese child who enjoys video games

Which of the following aspects of a computer determine its power? Select all that apply.

- Speed of operations - Data storage capacity

The nurse is assessing the level of consciousness of a client who suffered a head injury. She uses the Glasgow Coma Scale and determines that the client's score is 15. Which responses did the nurse assess in this client? Select all that apply.

- Spontaneous eye opening - Orientation to person, place, and time - Motor response to pain localized

Which of the following actions represent proper body mechanics for nurses providing care as well as teaching patients about safe body movements? Select all that apply.

- Stand with the body in alignment and erect posture. - Use a wide base of support with your feet at shoulder width. - Keep objects close to your body when carrying them.

Strategies to improve the status of nursing include which of the following? Select all that apply.

- Standardizing the educational requirements for entry into practice - Enacting uniform continuing education requirements - Encouraging participation in professional organizations

The nurse is examining a client who reports a history of peripheral venous abnormalities. What would the nurse expect to find during the examination? Select all that apply.

- Stasis ulcers - Lower extremity edema - Brown skin discoloration

A 64-year-old patient just returned from surgery. She is breathing rapidly and moving constantly in bed. She states, "I am scared and I hurt so much." What would be an appropriate intervention? Select all that apply.

- State calmly, "I am going to do everything I can to make you more comfortable." - Tell the patient you would like to help her calm down and take some deep breaths. - Ask the nursing assistive personnel to stay with the patient while you get an analgesic for her.

A mother tells the nurse she is worried that her 20-year-old daughter lacks the understanding regarding the need for follow-up care after her discharge. Which of the following behaviors suggests that the patient needs further discharge teaching? Select all that apply. The patient:

- States she does not understand much English - Watches television while the nurse is speaking to her

There are various cardiovascular medications that lower cholesterol. Which medication category lowers LDL cholesterol levels?

- Statins

When assessing the quality of a client's pedal pulses, what is the nurse assessing? Select all that apply.

- Strength of the pulses - Bilateral equality of pulses

Which events can create imbalance of circulation and perfusion? Select all that apply.

- Stress - Obesity - Pregnancy - Illness - Medications

Types of urinary incontinence

- Stress incontinence - Urge incontinence - Nocturnal enuresis - Overflow incontinence - Functional incontinence

The nurse is caring for a client admitted with a sodium level of 151 mEq/L. Which would be the anticipated admitting orders? Select all that apply.

- Strict I&O monitoring. - Administer an IV of D5 NS at 125 mL/hr. - Monitor serum electrolytes every 4 hr.

The nurse notes that the client is experiencing respiratory distress. Which assessment changes support this finding? Select all that apply.

- Stridor - Wheezing - Grunting - Nasal flaring

Which procedure can the nurse safely delegate to the certified nursing assistant who is knowledgeable and experienced in the procedure?

- Suctioning the oropharynx

Which interventions are helpful when caring for a client with impaired vision? Select all that apply.

- Suggest the client use soft, diffuse lighting. - Offer large-print books and reading material. - Clean the client's eyeglasses daily. - Place call light and necessary items within reach.

Which of the following members of the operative team use sterile technique during the surgical procedure? Select all that apply.

- Surgeon - Scrub nurse - Registered nurse first assistant

The nurse is preparing instructions for a client who is being discharged after undergoing a barium enema. What should be included in the teaching? Select all that apply.

- Take a mild laxative after the procedure. - Increase oral fluid intake after the procedure. - Stools will be light colored for 2 to 3 days after the procedure.

Which instructions should the nurse provide a client to prepare for a colonoscopy? Select all that apply.

- Take laxatives as prescribed for the bowel prep. - Do not eat or drink anything after midnight prior to the test. - Have someone drive you home from the test due to sedation used in the procedure.

Which of these communication strategies are most useful when interacting with a client who has a hearing deficit? Select all that apply.

- Talk in an even tone of voice. - Use gestures and facial expressions. - Face the client directly when speaking.

Nurses frequently encounter death of patients in many healthcare settings. What are some strategies nurses can use to better care for themselves when dealing with death and the dying? Select all that apply.

- Talk with colleagues about your feelings related to death and dying. - Take time for yourself through relaxation and focusing on peaceful thoughts. - Have a good understanding of your own feelings about death and dying.

A 70-year-old homeless man is admitted to the emergency department with heat stroke following 3 days of overexposure to outside temperatures. The nurse is most alerted to which signs and symptoms associated with heat stroke? Select all that apply.

- Temperature of 103.8°F - Throbbing headache - Confusion

The nurse from the local high school is giving a presentation to 16-year-olds on safety risks associated with driving. Which of the following will the nurse include in the presentation as being high-risk activities for motor vehicle crashes while driving? Select all that apply.

- Texting - Drinking alcohol

The nurse is caring for a patient diagnosed with a brain tumor who is about to undergo surgery to have the tumor removed. Before the surgery, the patient signs a document giving instructions to his family regarding the level and extent of life-prolonging treatments he desires. Which of the choices below describe this legal directive? Select all that apply.

- The document is a living will. - The family can make decisions that are consistent with the document if the patient is incompetent. - The family has guidance on the treatments the patient wants.

Which of the following describes the Perioperative Nursing Data Set? Select all that apply.

- The first specialized nursing language recognized by the ANA - A standardized language designed to describe the care of perioperative patients

Which of the following are considered normal processes and changes in the urinary system that occur with aging in older adults? Select all that apply.

- The number of functional nephrons decreases with age. - The volume of urine that the bladder can hold lessens with age. - Loss of bladder elasticity leads to urinary retention.

The nurse arrives at work to find the unit will be short staffed for the shift because a nurse called in sick at the last minute, leaving no time to find a replacement. What factors contribute to the dilemma faced by the nurse working this shift? Select all that apply.

- The nurse's multiple obligations and relationships - Value conflicts and lack of clarity within the profession - Caring versus the decreased time to spend with patients

The nurse is reviewing the results of the patient's laboratory findings and notes an elevated C-reactive protein (CRP). What does this indicate?

- The patient has inflammation in the body.

The health-care team is determining discharge plans for a client admitted after involvement in a motor vehicle accident. The client requires intravenous antibiotics as well as physical and occupational therapy and wants to receive these services in the home. Which factors determine if this is appropriate? Select all that apply.

- The presence of help in the client's home. - The coverage provided by the client's insurance carrier. - The complexity of the care required by the client. - The availability of a home health-care agency to provide the required services. - The ability of the client to be transported to and from health-care provider appointments.

Which statement(s) about nursing interventions is/are true? Select all that apply.

- The responsibility of writing nursing orders cannot be delegated to the LPN/LVN. - Nursing interventions should be individualized and culturally sensitive.

The community health nurse is preparing a teaching plan on motor vehicle accidents. What information will the nurse include in the plan? Select all that apply.

- The risk of being injured or killed in a car crash increases for older adult drivers. - Cell phone use while driving is directly correlated with an increase in motor vehicle accidents.

The nurse knows that the electrical conduction in the heart can impact the process of circulation. What else can impact circulation? Select all that apply.

- The strength of the heart's contractions - The volume of blood in the body - The resistance that the heart pumps against

The nurse educator in the local hospital is developing a plan to implement research into nursing care practices. What are some of the barriers she may encounter in this implementation process? Select all that apply.

- There is a negative attitude toward research. - There is a lack of support from the employing hospital.

Patients may fail to comply with a proposed healthcare regimen and therefore are perceived to be noncompliant. Identify common reason(s) a patient may be noncompliant with a plan of care? Select all that apply.

- There is no available support system in place to assist with compliance. - The patient does not understand the plan. - The plan of care is inconvenient.

The nurse educator in the local hospital is preparing a teaching plan for staff nurses on using medication abbreviations in nursing documentation. What is most important for the nurse to include in the teaching plan concerning acceptable abbreviations? Select all that apply.

- They are based on Joint Commission recommendations. - They are based on policies of the facility.

Two days after a patient undergoes abdominal surgery, his surgical incision is red and slightly edematous; it is oozing a small amount of serosanguineous (pink-tinged serous) fluid. On the basis of these data, what can you conclude? Select all that apply.

- This is a vascular response to inflammation. - Exudate formation is occurring.

What factors regarding nutrition should the nurse consider when working with an older adult? Select all that apply.

- Tooth loss and gum disease limit chewing ability. - It is not unusual for older adults to lose interest in eating and for the thirst sensation to decrease. - The ability to taste and smell diminishes with age, and many clients find some diets unappealing. - Arthritic hands may create difficulty preparing and eating food.

Included on Nutrition Facts Label

- Total fat - Sodium - Protein - Calories from fat - Serving size

What should you include in a plan for teaching adults about dietary trans-fatty acids? Select all that apply

- Trans fat increases the shelf-life of foods. - The FDA mandates that trans fat content be listed on all food labels. - Check for hydrogenated vegetable oils on food labels.

The nurse in the intensive care unit enters her patient's room and observes the patient is experiencing a seizure. What are the most appropriate interventions by the nurse? Select all that apply.

- Turn the patient to his side. - Loosen any restrictive clothing. - Pad the siderails of the patient's bed.

The nurse is preparing to administer a subcutaneous does of insulin to a patient with diabetes. Which two sites might the nurse use that would provide the best absorption of the injection? Select all that apply.

- Upper arm - Abdomen

Symptoms of urinary tract infection

- Urinary frequency - Nausea and vomiting - Dysuria - Back pain - Urgency - Fever and chills

The nurse would anticipate which symptoms for a client with a suspected urinary tract infection (UTI)? Select all that apply.

- Urinary frequency - Urinary urgency

The nurse is concerned about fluid loss for the at-risk client. What should be included in the output measurement? Select all that apply.

- Urine - Emesis

The nurse is educating unlicensed nursing assistive personnel (NAP) about recording output for a client. What fluids should the nurse include in the output for accuracy? Select all that apply.

- Urine - Emesis - Diarrhea - Nasogastric drainage

A client is recently diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH), causing excess release of antidiuretic hormone. Symptoms include headache, weight gain, and nausea. What additional assessments are a priority? Select all that apply.

- Urine output - Respirations - Blood pressure

The nurse plans to maintain hydration for the patient at risk for thrombus formation. What evaluation finding is an indicator that the intervention is successful?

- Urine output exceeds 1,500 mL per 24-hour period.

The nurse is caring for a patient who is normally healthy but is experiencing dehydration secondary to acute diarrhea and vomiting. What assessment findings would indicate a return to fluid homeostasis? Select all that apply.

- Urine output of 35 mL/hour - Reduced renin production - Reduced aldosterone release

The nurse is caring for a postoperative client with an oxygen saturation of 90% who has fine crackles in both lung bases. Which intervention would be most effective in improving this client's respiratory status?

- Use an incentive spirometer.

Which are interventions used to manage and minimize the symptoms of dry mouth? Select all that apply.

- Use hard candy or gum - Take frequent sips of water - Use lip moisturizer

The implementation of electronic health records (EHRs) allows the nurse to do which of the following? Select all that apply.

- Use trend data to facilitate evidence-based nursing practice - Promote efficient use of time spent charting - Activate the system's safeguards to promote client safety

Which statement(s) about communication is/are true? Select all that apply. Communication is:

- Used to meet physical and psychosocial needs - The process of sending and receiving information - The basis for forming relationships

The nurse is teaching a group of newly hired nursing assistive personnel (NAP) about proper handwashing. The nurse will know that the teaching was effective if the NAP demonstrate which of the following? Select all that apply.

- Uses a paper towel to turn off the faucet - Removes all rings and watch before washing hands - Cleans underneath each fingernail

The American Nurses Association (ANA) has set standards for registered nurses in utilizing evidence-based interventions and treatments in practice. According to the ANA, which of the following statement(s) best describes these standards? Select all that apply. The registered nurse:

- Uses current evidence-based nursing knowledge to guide practice decisions - Critically analyzes evidence-based practice and research findings for application to practice - Shares research activities and findings with peers and others

What are common beliefs and practices associated with the North American (Western) professional healthcare system? Select all that apply.

- Values emphasize individualism and self-reliance. - Health is defined as absence or minimization of disease. - Reliance is on the biomedical system.

Which statements about nutrition are correct? Select all that apply.

- Vegetables can be eaten with other vegetables to make a complete protein. - Carbohydrates raise blood glucose levels. - Micronutrients are foods that are consumed in small amounts.

A client reports to the emergency room with shortness of breath and chest pain. The health-care provider suspects a pulmonary embolism. For which test should the nurse prepare the client?

- Ventilation-perfusion scan

A 73-year-old patient admitted after a stroke has expressive aphasia. Which pain intensity scales would be appropriate to use with this patient? Select all that apply.

- Visual analogue - Numerical rating - Wong-Baker face rating

The pediatric nurse is preparing a teaching plan about vitamins for parents of school-age children. What vital information will the nurse include in the plan? Select all that apply.

- Vitamins are needed for cellular metabolism. - Vitamins are necessary for preventing particular deficiency diseases. - Because the body does not make vitamins, they must be supplied by the foods we eat.

Which of the following best describes "meaningful work"? Select all that apply.

- Volunteering in the children's ward at the local hospital - Starting a garden club in your community - Playing an instrument in a rock-and-roll band

The nurse is teaching a group of school-age children about diet and nutrition. What recommendations should the nurse make about the USDA dietary guidelines? Select all that apply.

- Wash hands before and after meals. - Avoid empty calorie snacks

The nurse is speaking to her neighbor, whose child has had diarrhea for 24 hours. What suggestion should be made? Select all that apply.

- Wash hands often. - Increase hydration with popsicles. - Eat bananas, rice, applesauce, and toast.

Carl has poor arterial circulation, and the nurse is providing patient teaching regarding proper foot care. What should the nurse include in her teaching? Select all that apply.

- Wear smooth, dry socks. - Apply lotion to the feet. - Wear well-fitting shoes.

Which of the following are examples of nonselective mechanical debridement methods? Select all that apply.

- Wet-to-dry dressings - Whirlpool - Pulsed lavage

What should be included in a perioperative client teaching plan? Select all that apply.

- What will happen before, during, and after surgery - What can be done to prevent surgical site infection - Common concerns related to the procedure

The nurse, working in the postanesthesia care unit inserts an oral airway into the semiconscious patient to prevent airway obstruction. When should the airway be removed?

- When the patient removes it

The nurse is caring for a client with postsurgical pain. At what point is it important to assess the pain level? Select all that apply.

- When there are nonverbal cues of pain - At the beginning of the shift - After physical activity - Before physical activity

In which situation would using standard precautions be adequate? Select all that apply.

- While aiding a client to ambulate after surgery - While inserting a peripheral intravenous catheter

To promote wound healing, the nurse is teaching a patient about choosing foods containing protein. Which foods are incomplete proteins that should be consumed with a complementary protein? Select all that apply.

- Whole grain bread - Peanut butter - Refried beans

To promote wound healing, the nurse is teaching a patient about choosing foods containing protein. The nurse will evaluate that learning has occurred if the patient recognizes which food(s) is an incomplete protein that should be consumed with a complementary protein? Select all that apply.

- Whole grain rice - Lentils

The nurse is asked for a list of bulk-forming foods to be included in a patient's diet. What should be included? Select all that apply.

- Whole grains - Dried beans

A community health nurse is assigned to work in a different area of the city. Which of the following assessment techniques would she likely use to develop an overview of the community? Select all that apply.

- Windshield survey - Review of demographic data

The nurse is visiting a patient who lives alone in a two-room house. The patient requires wound care and medication management, but his health is not expected to improve much, even with care. There is no running water in the house, and the bathroom is in disrepair and filthy. At the first home visit, which of the following should the nurse assess? Select all that apply.

- Wound status - Patient concerns - Ability to perform care independently

Why is it important for you as a nurse to understand stress and adaptation? Select all that apply.

- You need to identify your own stressors and develop healthy adaptation responses. - Understanding stress will help you identify client stressors and adaptive responses.

A client with irritable bowel syndrome reports excess gas after meals. Which foods should the nurse instruct the client to avoid in the diet to decrease gas production? Select all that apply.

- beans - onions - broccoli

The nurse is educating a group of older adults about constipation. Which gerontological changes should the nurse include in the session? Select all that apply.

- diminished mobility - lowered fluid intake - decreased peristalsis - changes in fiber intake

To promote mobilization of the pneumonia secretions, which actions should the nurse include in the plan of care? Select all that apply.

- encourage cough and deep breathing - maintain hydration - perform chest physiotherapy.

Which are common disorders that are primary causes of bowel function? Select all that apply.

- food allergies - diverticulosis - food intolerance

A nurse is preparing to obtain a sputum specimen from a male client. Which of the following nursing actions will facilitate obtaining the specimen?

- having the client take deep breaths

Which should be included in client teaching to support normal bowel elimination? Select all that apply.

- increase fluid intake - increase physical activity - do not ignore the urge to defecate

Which symptoms would the nurse expect to find in a female client experiencing a heart attack? Select all that apply.

- nausea - jaw pain - shortness of breath

As Mr. Martin's oxygenation deteriorates, the nurse has an order to titrate pulse oximetry to keep it greater than 90%. Because Mr. Martin is currently at 6 L/NC (44% oxygen), what would be the best options for delivery of oxygen should the levels drop below 90%? Select all that apply.

- simple mask - partial rebreather mask - venturi mask - face tent

The health-care provider prescribes a transfusion of a unit of packed red blood cells for a client. Which type of intravenous (IV) fluid should the nurse use?

0.9% normal saline

The nurse is caring for a client admitted with Clostridium difficile who has multiple bouts of diarrhea. Which fluid would the nurse expect to be prescribed by the health-care provider?

0.9% sodium chloride

The nurse notifies the primary care provider that the patient is experiencing pain. The provider gives the nurse a telephone prescription for morphine 4 mg intravenously every hour as needed for pain. How should the nurse document this telephone order?

09/02/16 0845 morphine 4 mg intravenously q 1 hour prn pain T.O.: Dr. D. Kelly/Kay Andrews, RN

Nurses use a five-step process in selecting the best nursing interventions for their patients. Using the five-step process in selecting the best nursing interventions, arrange the list on the left in the correct order of completion on the right.

1. Review the nursing diagnosis. 2. Review the desired outcomes/goals. 3. Identify several actions or interventions. 4. Choose the best interventions for the patient. 5. Individualize standardized interventions.

What are the appropriate procedural steps for administering parenteral nutrition?

1.) Gather supplies and explain the procedure to the client. 2.) Wash hands, don gloves, and position the client in supine position. 3.) Examine the PN container for leaks, cloudiness, and floating particles. 4.) Compare the PN bag to the client's identification. 5.) Connect the IV tube to the PN and place the IV tubing in the infusion pump. 6.) Identify the correct IV catheter and lumen for PN. 7.) Clamp the catheter and the old PN administration set if still connected and remove/discard gloves. 8.) Don sterile gloves (or clean gloves) and inspect the patency of line. 9.) Attach the infusion tubing to the designated PN port and turn the luer-lock to secure the connection. 10.) Trace tubing from the client back to the bag, then label the tubing with the date and time of change.

Place in order the steps for educating the client to move in bed.

1.) Identify the client 2.) Place the client in a supine position 3.) Instruct client to bend the right leg and turn to the left side 4.) Reach right arm toward opposite bedrail 5.) Teach client to take deep breaths and splint the abdomen 7.) Client should pull on the bedrail while pushing off with the right foot 8.) Repeat every 2 hours while awake

A client's vital signs at the beginning of the shift are as follows: oral temperature 99.3°F (37°C), heart rate 82 beats/min, respiratory rate 14 breaths/min, and blood pressure 118/76 mm Hg. Four hours later, the client's oral temperature is 102.3°F (39.1°C). Based on the temperature change, the nurse should anticipate the client's heart rate would be how many beats/min?

102

The parents of a 12-year-old boy refuse chemotherapy to treat the child's leukemia, saying they will not ruin what is left of his life with drugs that will make him feel sicker. Which solution to this ethical dilemma would demonstrate compromise, maintaining the integrity of all involved?

Agreeing to administer the chemotherapy agent with the fewest side effects.

A patient is admitted to the hospital with tuberculosis. Which precautions must the nurse institute when caring for this patient?

Airborne transmission

An individual begins grasping for air and makes an unusual high-pitched, harsh, crowing sound. What could be occurring?

Airway obstruction

A healthcare provider prescribes 250 mL of 0.9% sodium chloride to be infused over 2 hours. A microdrip infusion set is being used. What is the drip rate (drops/min) that the nurse should monitor?

125

The nurse conducts an assessment of a 38-year-old patient's fitness using the step test. At the end of the test, which heart rate would indicate the patient is in very poor physical condition?

134 beats/min

When testing near vision, the nurse should position printed text how many inches away from the patient?

14

A healthy 32-year-old man wants to start a fitness program to increase his muscle tone and muscle strength. What advice should the nurse offer him? "The U.S. Department of Health and Human Services recommends:

150 to 300 minutes or more of moderate-intensity physical activity per week"

A patient is given furosemide 40 mg orally at 0900. The duration of action for this drug is approximately 6 hours after oral administration. At which time in military hours should the nurse no longer expect to see the effects of this drug?

1500

A client's vital signs 4 hours ago were temperature (oral) 101.4°F (38.6°C), heart rate 110 beats/min, respiratory rate 26 breaths/min, and blood pressure 124/78 mm Hg. The temperature is now 99.4°F (37.4°C). Based only on the expected relationship between temperature and respiratory rate, the nurse might best anticipate the client's respiratory rate to be:

18

The nurse reviews the client's medical record and notices a prescription for 0.45% normal saline to infuse at 75 mL/hour. The tubing provides 15 gtts/mL. How many drops per minute will the nurse set the fluids to infuse? Enter numeral only.

19

For which patient in the emergency room is it most important that the nurse conduct a thorough assessment for abuse and neglect?

2-year-old Caucasian male with injuries from a fall

Which of the following older adult patients needs to increase his daily fluid intake? One who typically drinks (assume three meals per day):

250 mL at each meal, plus 600 mL throughout the day

Your patient has a deep wound on the right hip, with tunneling at the 8 o'clock position extending 5 cm. The wound is draining large amounts of serosanguineous fluid and contains 100% red beefy tissue in the wound bed. Of the following, which would be an appropriate dressing choice?

Alginate dressing

It is important for nurses to be critical thinkers because:

All clients are unique and have individual needs and differences

The nurse is gathering supplies to perform a central venous catheter dressing change. Which finding in the medical record requires the nurse to slightly change the procedure?

Allergy to shellfish

The student informs her preceptor that the acronym "AND" is being recommended to replace "DNR" for patients who do not want to be resuscitated. What does the acronym "AND" stand for?

Allow natural death

Considering normal developmental and physical maturation in children, for which age would a goal of "Achieves bowel control by the end of this month" be most realistic?

3 years

The nurse is preparing to remove an indwelling urinary catheter from a client who underwent a prostatectomy a week ago. Which size syringe would be most appropriate for the nurse to use to deflate the retention balloon?

30 mL

The nurse is teaching parents ways to give oral medication to their child. Which action would they implement to improve compliance?

Allow the child to eat a frozen pop before receiving the medication.

The preoperative nurse is caring for a client preparing to undergo surgery. The client is crying and upset about the upcoming surgery. The client feels nervous and is unable to calm down. Which medication should the nurse administer to alleviate these feelings?

Alprazolam

A child has an inflamed epiglottis from a viral infection, causing stridor and partially blocking the flow of air. Which type of breathing problem is present?

Altered airway

Which is not a professional value identified by the American Association of Colleges of Nursing (AACN)?

Altruism

Which of the following is considered a "practice" (as opposed to a belief or value)?

Always drinking water after exercise

Which piece of information is most important for the nurse to obtain prior to removing an indwelling urinary catheter?

Amount of saline in balloon

The staff RN is assigned to an operation with an operating room LPN. The physician employs another RN who will be first assistant for the operation. What role will the staff RN play?

Circulating nurse

Which surgical team member performs the role of coordinating all activities in the operating room?

Circulating nurse

The nurse has an order to obtain a urine specimen for a culture and sensitivity test from a client with an indwelling urinary catheter. Which procedure is accurate for obtaining the specimen?

Clamping the tubing and withdrawing a fresh specimen from the tubing aseptically

A surgeon prescribes heparin 2,500 mEq IM q 12 hr. What is the nurse's best action?

Clarify the dose and route with the surgeon.

Which of the following is a correct step in removing and cleaning a hearing aid?

Clean the top part of the canal portion of the device.

A urine specimen is obtained by a client cleaning the exterior meatus, then beginning to void, then collecting the urine sample midstream. Which type of specimen does this describe?

Clean-catch specimen

The diagnostic label, or patient problem, is used primarily to suggest:

Client goals

While conducting research on weight management among Native Americans, what information would be integral in developing a theory?

Client preferences regarding weight management (timing, location and costs) and how meeting these preferences will influence success.

A client is about to go to the preoperative holding area and is given a strong narcotic sedating agent. The spouse accompanies the client to the holding area. Once there, the surgeon goes over the informed consent and asks for a signature. What should occur in this scenario?

Client's spouse should sign the form

What is meant by full-spectrum nursing?

Clients are treated by nurses who use well-rounded skills such as critical thinking and communication in addition to technical skills and safe and effective care.

The nursing instructor notices a client who is in pain does not have a pulse oximeter in use and suggests to the student that one should be attached. Why?

Clients in pain tend to breathe shallowly, which increases the risk for atelectasis.

Using the nursing process to carefully consider a client's condition is an example of which skill?

Clinical judgement

The nurse assists a surgeon with central venous catheter insertion. Which action is necessary to help maintain sterile technique?

Closing the patient's door to limit room traffic while preparing the sterile field

In his later work, Maslow identified growth needs that must be met before reaching self-actualization. These needs include:

Cognitive and aesthetic needs

The community health nurse is working with the residents of government-subsidized senior housing. She meets with them regularly to discuss concerns and evaluate whether they receive healthcare that meets their needs. Which of the following nursing roles best describes these actions?

Collaborator

The healthcare team suspects that a patient has an intestinal infection. Which action should the nurse take to help confirm the diagnosis?

Collect a stool specimen that contains 20 to 30 mL of liquid stool.

The nurse obtains the following information from the patient: Alert and oriented, is married, and has a history of heart disease. This is an example of:

Collecting data

According to the U.S. Department of Health and Human Services 2008 Physical Activity Guidelines for Americans, which of the following statements about the benefits of physical activity is correct?

Combining aerobic and muscle-strengthening activities promotes better health.

Which imbalance is present with the following ABG values: pH 7.40, PCO2 51, HCO3 34?

Compensated metabolic alkalosis

The physician prescribes warfarin 5 mg orally at 1800 for a patient. After administering the medication, the nurse realizes that she administered a 10 mg tablet instead of the prescribed 5 mg PO. Which of the following actions by the nurse is appropriate?

Complete an incident report according to the facility's policy.

A patient is admitted to the emergency department (ED) in respiratory distress. The results of his first arterial blood gases were pH = 7.30; PCO2 = 40; HCO3 = 19 mEq/L; PO2 = 80. The nurse evaluates the patient's treatment plan by examining repeat arterial blood gases (ABGs). The results are pH = 7.38; PCO2 = 32; HCO3 = 19 mEq/L. The nurse concludes which of the following?

Complete compensation; the treatment plan is effective.

A patient complains of pain after undergoing surgery. The nurse forms a mental image of pain based on her own experiences with pain. This mental image is known as a(n):

Concept

The nurse is facing a moral dilemma and applies the MORAL model to decision making. After writing down all the possible options to solve the problem, what will the nurse do next?

Consider all the options and choose the best one.

A patient with trigeminal neuralgia is prescribed a mechanical soft diet. This diet places the patient at risk for which complication?

Constipation

A psychiatrist prescribes oral aripiprazole 10 mg daily for a client with schizophrenia. This medication is unfamiliar to the nurse, and she cannot find it in the hospital formulary or other references. How should she proceed?

Consult with a pharmacist before administering it.

Before entering the room of a patient who is angry and yelling, the nurse removes her stethoscope from around her neck. The best rationale for doing so is that the stethoscope:

Could be used by the patient to hurt her

A client is recovering from cardiac surgery in which vein grafts were taken from his lower leg. He informs the nurse that his leg is warm and tender in his right calf, just below the surgical incision site. The nurse notes erythema and swelling. What complication is suspected?

Deep vein thrombosis

The nurse is caring for an immobile patient with chronic, unrelieved pain that is frequently severe. For what potential complication should the nurse monitor?

Deep vein thrombosis

A patient has been vomiting for 2 days and has not been able to eat or drink anything during this time. She has not urinated for 12 hours. Physical examination reveals the following: T = 99.6°F (37.6°C) orally; P = 110 beats/min, weak and thready; BP = 80/52 mm Hg. Her skin and mucous membranes are dry, and there is decreased skin turgor. The patient states that she feels very weak. The following are her laboratory results: Sodium 138 mEq/L Potassium 3.7 mEq/L Calcium 9.2 mg/dL Magnesium 1.8 mg/dL Chloride 99 mEq/L BUN 29 mg/dL Which of the following is an appropriate nursing diagnosis for this patient?

Deficient Fluid Volume related to abnormal fluid loss

A patient with attention deficit disorder is admitted to the hospital with type 1 diabetes. Which nursing diagnosis is commonly yet inappropriately used but should be avoided for this type of patient? Assume there are data to support all the diagnoses.

Deficient Recall (disease process)

When making a diagnosis using NANDA-I, which of the following provides support for the diagnostic label you choose?

Defining characteristics

A client presents to the emergency department with nausea and vomiting for 2 days. The client states he or she has not urinated at all for the past 8 hours. Which is the most likely cause of lack of urine output?

Dehydration

When Alexia was 17 years old, she lost her mother. She put all her energy into caring for her three younger siblings. Two years after her mom's death, a casual acquaintance was killed in a car accident. She tells the nurse, "I had a harder time with that than I did with my mom's death." What could Alexia be experiencing?

Delayed grief

A 76-year-old patient is admitted with an acute myocardial infarction (heart attack). The doctor tells the patient that an angioplasty is necessary. The patient agrees and signs the informed consent. This patient is experiencing which stage of illness behavior?

Dependence on others

The nurse caring for a patient with unresolved anger. For which associated complication should the nurse assess?

Depression

Which of the following describes the most important use of making a nursing diagnosis? Assume all are true.

Describes the client's needs for nursing care

The nurse is individualizing Mr. Wu's plan of care by writing a plan for his nursing diagnosis of Anxiety. The nurse needs to write goals/outcomes on the plan of care because outcomes describe:

Desirable changes in the patient's health status

A client is admitted to the hospital with an acute respiratory problem resulting from lung disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations. Which nursing intervention should be listed first on the care plan?

Determine airway adequacy hourly and as needed.

The nurse is caring for a client who was newly diagnosed with type 2 diabetes mellitus. Which intervention by the nurse best promotes client cooperation with the treatment plan?

Determining the client's main concerns about his diabetes

A home health nurse has called his patient to arrange an initial home visit and has driven to the home. What is the nurse's objective in the first few minutes of the visit?

Develop rapport and trust with the patient and family.

What is considered a risk factor for a urinary tract infection?

Diabetes

The nurse has gathered her assessment data and notes several significant changes in the client's health status. The client's weight has increased by 5 lb over the past 24 hours, he is short of breath, and crackles are auscultated at both lung bases. To which step of the Nursing Process should the nurse proceed after organizing these data?

Diagnosis

The admission assessment form indicates that the patient has pedal pulses that are rated 1 in amplitude. This documentation indicates that the patient's pulses are:

Diminished

A family caregiver is learning to administer insulin injections to her homebound sister. What should the nurse advise her to do with the used needles?

Discard the needle and syringe in a thick plastic milk jug with a lid.

The nurse is obtaining vital signs on a newborn infant and notes respirations at 56 breaths/min. What is the most appropriate action by the nurse?

Document the finding and continue the assessment.

A 1-day postoperative client has a temperature of 36.8°C. What is the nurse's next best action?

Document the temperature and continue with his care.

The nurse in the local nursing home is planning a memory activity for the older adult residents. What is the most effective activity she might use to enhance memory?

Doing a crossword puzzle

What position should the patient assume before the nurse inserts an indwelling urinary catheter?

Dorsal recumbent

The nurse must irrigate the ear of a 4-year-old child. How should the nurse pull the pinna to straighten the child's ear canal?

Down and back

What intervention would be most appropriate for a wound with a beefy red wound bed?

Dressing to keep the wound moist and clean

Which side effects associated with opioid use may improve after taking a few doses of the drug?

Drowsiness

Which of the following outcome statements contains the best example of performance criteria? The patient will:

Eat 75% of each meal without complaint of nausea

The client is a 76-year-old man who is experiencing chronic illness. He has a genetic-linked anemia. He says he does not eat a balanced diet, as he prefers sweets to meat and vegetables. Which of the following dimensions of health can the nurse most likely influence by teaching and counseling him?

Eating habits

A nurse identifies a patient's nursing diagnosis as "Diarrhea related to stress." Which nursing intervention should be included in the nursing care plan to help the patient relieve the cause of the diarrhea?

Encourage the patient to verbalize about stressors and anxiety

Prior to discharge, a patient with diabetes needs to learn how to check a finger-stick blood sugar reading before taking insulin. Which action will best help the patient remember proper technique?

Encouraging the patient to check the blood sugar each time the nurse gives insulin

A patient becomes infected with oral candidiasis (thrush) while receiving intravenous antibiotics to treat a systemic infection. Which type of infection has the patient developed?

Endogenous nosocomial

A 26-year-old man of Mexican heritage is admitted for observation after sustaining injuries in a motor vehicle accident. When assessing this patient, the nurse must consider that he may possess which view of pain? He may:

Endure pain longer and report it less frequently than some patients do

A 16-year-old boy recently lost his father in a tragic motorcycle accident. In assessing how well this teenager is managing and coping with the death of his father, the nurse should be most alert for:

Engaging in health risk behaviors

The focus of nursing care in the intraoperative phase is to:

Ensure patient safety during the surgery

A patient is in crisis. After assessing the situation, what should the nurse do first?

Ensure the safety of both the nurse and patient

A 73-year-old patient who suffered a stroke is being transferred from the acute care hospital to a nursing home for ongoing care because she is unable to care for herself at home. Which type of loss is this patient most likely experiencing?

Environmental

What is the primary goal of the National League for Nursing?

Establish and maintain standards for nursing education

Which is a description of nurses being able to apply standards of ethical conduct to professional practice and participate in ethical decision making?

Ethical agency

A nurse is providing care to a patient who is a Jehovah's Witness. Against the patient's wishes, the physician ordered the nurse to give the patient two units of packed red blood cells. The nurse knows that the blood will save the patient's life, but also that it is against the patient's wishes; she is unsure what is the right thing for her to do. The nurse is experiencing a(n):

Ethical dilemma

Which of the following concepts refers to conflicts that arise between two or more ethical principles in patient care scenarios?

Ethical dilemma

At a clinical post conference, a nursing student states, "I had a Chinese patient today and while I understand some of her cultural practices, she needs to understand that she is in the United States now and should follow our practices because we use scientific evidence." Which cultural barrier is the student demonstrating?

Ethnocentrism

The nurse documents in the client plan of care that the wound treatment to the client's left foot has resulted in wound healing. She removed the Skin Integrity diagnosis from the plan of care. The nurse is using which aspect of the Nursing Process?

Evaluation

A resident in a long-term care facility is unable to provide self-care owing to dementia and is receiving Medicare funds. How often must the nurse document this resident's care?

Every 3 months

A postsurgical patient has just returned from the recovery room to the surgical unit. After the first hour on the unit, what is the likely schedule for measuring the patient's vital signs?

Every 4 hours for 24 hours

According to the Centers for Disease Control (CDC), how often should the nurse change the intravenous (IV) tubing for a continuous infusion?

Every 96 hours

When should the nurse collect evaluation data for this expected outcome? "Patient will maintain urine output of at least 30 mL/hour."

Every hour

Which of the following unique aspects of home care do Medicare reimbursement regulations require that the nurse include in documentation?

Evidence of homebound status and continued need for skilled care

A pregnant 15-year-old girl presents to the emergency department (ED) of the local private hospital. She has been transported by her mother and appears to be in active labor. The girl is crying uncontrollably and says she is scared and experiencing painful contractions. Her mother states, "We don't have any money or insurance, but this hospital is closer than the public hospital, and she needs help now." What is the first step that the ED staff should take?

Examine her to determine whether her condition is stable or whether she requires immediate medical attention.

What is the primary difference between acute and chronic wounds? Chronic wounds:

Exceed the typical healing time, but acute wounds heal readily

A home health patient previously lived with her sister for more than 20 years. Although it has been more than a year since her sister died, the patient tells the nurse, "It's no worse now, but I never feel any relief from this overwhelming sadness. I still can't sleep a full night. The house is a mess; I feel too tired even to take a bath. But, sometimes at night, she comes to me and I can see her plain as can be." The patient's clothing is not clean and her hair is not combed. She is apparently not eating adequately. What can the nurse conclude? The patient is probably

Experiencing a depressive disorder rather than simply grieving the loss of her sister

An experienced seasoned nurse uses her knowledge of patient medical conditions and intuition to identify patient problems. She is often the resource for other nurses on the unit. What stage of proficiency has this nurse achieved?

Expert

The nurse asks a client who underwent a hip replacement to rate his or her pain level. The client states it is a 6 on a scale of 0 to 10 but is fine with this level and does not want pain medication. What should be the nurse's next action?

Explain it is better to take medication when pain is minimal.

A bowel prep "until clear" is prescribed for the female client scheduled for a colonoscopy. The client begins to experience diarrhea following administration of the solution. What action by the nurse is appropriate?

Explain that diarrhea is expected.

A mother tells the nurse at an annual well child checkup that her 6-year-old son occasionally "wets himself." Which response by the nurse is appropriate?

Explain that occasional wetting is normal in children of this age.

Which intervention by the nurse would be best to motivate a patient newly diagnosed with hypertension to learn about the prescribed treatment plan?

Explain that when left untreated, hypertension may lead to stroke.

How should the nurse respond to a family immediately after a patient dies?

Express sympathy to the family (e.g., "I am sorry for your loss").

The nurse enters a patient's room with a portable computer station to assess the patient. The nurse does not log out while assisting a patient to the bathroom. A visitor reads the patient's chart and begins to question the nurse about the patient information. This is an example of:

Failure to maintain patient confidentiality

A client is placed under involuntary confinement for suicidal ideation. During this time, the nurse applies restraints to insert a urinary catheter. Which situation has occurred?

False imprisonment

You are caring for an alert, oriented 47-year-old patient who is recovering from abdominal surgery. The patient becomes angry and upset and says, "I'm leaving this hospital. Remove my IV and surgical drains or I will do it myself." To keep him from removing his lines and leaving the hospital, you apply bilateral wrist restraints until you can contact the physician for an order for patient restraint. This is an example of which of the following?

False imprisonment

A nurse is caring for a patient who was newly diagnosed with type 1 diabetes. The patient's wife states, "We are a family of diabetics." The nurse advises the couple to attend the free nutrition, cooking, and exercise classes at the health center near their neighborhood. She also gives them the name of the public health nurse for their area. Which perspective of family nursing is the nurse practicing?

Family as a system

The nursing student is caring for a patient with diabetes on a medical-surgical unit. During a teaching session with the patient and family, she asks them questions regarding care at home, ability to perform blood glucose testing, and administering insulin. The student is providing family care using which perspective of family nursing?

Family as context for care

The patient verbalizes an overwhelming lack of energy. He says, "I still feel exhausted even after I sleep. I feel guilty when I can't keep up with my usual daily activities or sleep during the day. I've been a little depressed lately, too." The patient seems to have difficulty concentrating, but has no apparent physical problems. Which of the following diagnoses best describes his health status?

Fatigue related to depression

A client reports severe pain in the pubic area and the nurse determines the client has acute urinary retention. The client reports never experiencing this before. Which new medication may be the cause?

Fexofenadine

A patient has asked the nurse to explain her laboratory results. The nurse informs the patient that he must first assist another patient to the bathroom and then he will return to explain the results. After assisting the other patient to the bathroom, the nurse returns to explain the results to the patient. What ethical principle has the nurse displayed?

Fidelity

At a home visit, the nurse asks the patient, "Have you taken your blood pressure medicine today?" The patient replies, "I don't remember. Maybe." On the table are several bottles of medication, some open, some not. They have all been prescribed for the patient. The patient cannot say how often to take each one, when asked. A compartmentalized medication organizer is on the table, with a few capsules in it, and some compartments left open. What should the nurse do?

Fill the organizer for each day of the week; explain how to use it; and return in a day or two to evaluate.

Which action should the nurse take immediately after administering a medication through a nasogastric tube?

Flush the tube with water using a needleless syringe.

When preparing a room to receive a newly admitted patient, which of the following should the nursing assistive personnel (NAP) do?

Fold the top bed linens back to "open" the bed

The new nursing student is working on a surgical unit and observes some patients developing a low-grade fever of 99°F a few hours after their surgery. The most appropriate action for the student to take to gain some insight into her observation is to:

Formulate a searchable question and research the literature

A man has been admitted to the hospital unit with a medical diagnosis of Chronic Obstructive Pulmonary Disease (COPD). He is receiving supplemental oxygen at 2 L/min via nasal cannula. Which positioning technique will best assist him with his breathing?

Fowler's position

A client is admitted to the emergency department (ED). After treatment, the arterial blood gases are: pH = 7.38; PCO2 = 32; HCO3- = 19 mEq/L. What conclusions can the nurse make from this information?

Full compensation; the treatment plan is effective.

In caring for a patient with both diabetes and Impaired Skin Integrity (comorbidity), the nurse draws on her knowledge of diabetes and skin integrity. In a spirit of inquiry, she looks up the latest guidelines for providing skin care and includes them in the plan of care. The nurse provides skin care according to the procedural guidelines and begins regular monitoring to evaluate the effectiveness of the interventions. The nurse has demonstrated:

Full-spectrum nursing

A nurse is recently hired at an acute care facility. During orientation to her unit, she is given a role chart describing each person's role on the unit. The chart reflects that the registered nurses are responsible for all admission and discharge assessments and patient treatments. The licensed practical nurses are responsible for administering all medications and the certified nursing assistants obtain all vital signs and administer baths. The nurse recognizes this practice as which model of care?

Functional

A patient has left-sided weakness because of a recent stroke. Which type of special needs assessment would be most important to perform?

Functional

A client is given the instructions to avoid eating before bedtime, keep the head of the bed elevated at 30 to 40 degrees, and to avoid fatty foods, chocolate, and smoking. Which impaired digestive function is most likely for this client?

Gastroesophageal reflux

A patient who underwent surgery 24 hours ago is prescribed a clear liquid diet. The patient asks for something to drink. Which item may the nurse provide for the patient?

Gelatin

The patient tells the nurse, "I'm so nervous. I want to be knocked out for the surgery so that I don't know what is going on." When the nurse communicates with the surgeon and anesthetist, she tells them that the patient desires which type of anesthesia?

General anesthesia

What is the term for the amount of blood that is filtered in a minute?

Glomerular filtration rate

Which of the following best describes the legal definition of a nurse? Assume all education programs are accredited.

Graduate of a nursing education program and has passed the National Council Licensure Exam

Which intervention by the nurse helps to establish a trusting nurse-patient relationship?

Greeting the patient by name whenever entering the patient's room

What is the most frequent cause of the spread of infection among institutionalized patients?

Hands of healthcare workers

A mother of three young children is newly diagnosed with breast cancer. She is intensely committed to fighting the cancer. She believes she can control her cancer to some degree with a positive attitude and feelings of inner strength. Which of the following traits is she demonstrating that is linked to health and healing?

Hardiness

As the nurse suctions Mr. Martin via the nasopharyngeal airway, what would be an anticipated response?

Harsh coughing

Which is the best example of a critical-thinking attitude? The nurse:

Has a lively curiosity and enjoys discovering new ways of doing things

The nurse working in the emergency department is preparing heat therapy for one of the patients in the unit. Which one is it most likely to be?

Has lower back pain

Select the answer that best completes the following statement: The primary purpose of employing the full-spectrum nursing model is to:

Have a positive effect on a client's health outcomes

In order to evaluate a patient's acid-base balance, the primary provider has prescribed diagnostic tests to measure pH, PCO2, and HCO3 - . The nurse realizes that the patient will:

Have an arterial blood sample taken

Which of the following is an example of self-knowledge? The nurse thinks, "I know that I:

Have religious beliefs that may make it difficult to take care of some clients"

Which of the following is the best approach to validate a clinical inference?

Have sufficient supportive data

Which action should the nurse take to relax the vastus lateralis muscle before administering an intramuscular injection into the site?

Have the client assume a sitting position.

The nurse measures the urine output of a patient who requires a bedpan to void. Which action should the nurse take first? Put on gloves and:

Have the patient void directly into the bedpan

When performing a central venous catheter dressing change, which of the following steps is correct?

Have the patient wear a mask or turn his head away from the site.

Which of the following is an example of the most basic motivation in Maslow's Hierarchy of Needs?

Having adequate housing

The charge nurse uses a whiteboard located at the nurse's station to write the nurses' patient assignments and the patients' diagnoses. This is a violation of which of the following?

Health Insurance Portability and Accountability Act (HIPAA)

How are NANDA-I problem labels and NOC outcome labels alike? Both describe:

Health status in terms of human responses

A patient's jugular venous pressure measures 5 cm. This finding indicates:

Heart failure

The nurse notes an S3 heart sound while performing an assessment on a patient admitted with an acute myocardial infarction. The nurse notifies the physician of the finding, which most likely suggests:

Heart failure

The nurse is working with a client who is obese and reports having a sedentary lifestyle. What is the nurse's first action to promote this client's health?

Help the client identify goals for promoting health.

The nurse is caring for a patient with chronic low back pain. The patient reports taking 800 mg of ibuprofen tid for the past 12 years. For this patient, which lab result is most important for the nurse to review?

Hemoglobin and hematocrit

The nurse is caring for a patient experiencing dyspnea. Which position would be most effective to support ventilation?

High fowler's

The registered nurse is observing a nursing student administer a soapsuds enema to a client. Which action made by the student nurse requires correction?

Holding the container 45 to 60 cm above the hips

The nurse is caring for a client with severe diabetic ketoacidosis. Which electrolyte imbalance will occur as a result of the acidotic state?

Hyperkalemia

Iliana has been dealing with adrenal insufficiency for 5 years. She has hypotension, feels warm to touch, and is lethargic. Her reflexes are hypoactive. Which electrolyte imbalance is causing the problem?

Hypermagnesmia

Kimberly went on a hike with friends on a hot summer day. She did not take adequate amounts of water and is brought to the emergency department with a high fever, dry mouth, sticky mucous membranes, and hallucinations.Which electrolyte imbalance is causing the problem?

Hypernatremia

A patient's 2:1 parenteral nutrition container infuses before the pharmacy prepares the next container. This places the patient at risk for which complication?

Hypoglycemia

A patient is prescribed furosemide (Lasix), a loop diuretic, for treatment of congestive heart failure. The patient is at risk for which electrolyte imbalance associated with use of this drug?

Hypokalemia

A client on an ECG monitor begins having dysrhythmias. Which electrolyte imbalances are a concern? Select all that apply.

Hypokalemia Hypomagnesemia

A client with a history of chronic alcoholism is brought to the emergency department after falling. He is disoriented, with periods of calm and disruptiveness. He is having dysrhythmias on the cardiac monitor. What electrolyte imbalance could be causing the problem?

Hypomagnesemia

Eric has been an alcoholic for 10 years. He drinks daily and consumes the majority of his caloric intake this way. He is disoriented, irritable, and showing dysrhythmias on the cardiac monitor. Which electrolyte imbalance is causing the problem?

Hypomagnesmia

An older adult has been vomiting for 2 days and has not been able to eat or drink anything during this time. As the nurse enters the room, the client has a grand mal seizure. Which electrolyte abnormalities could be the cause? Select all that apply.

Hyponatremia

James is experiencing water intoxication as a result of psychogenic polydipsia, a condition compelling him to drink excessive amounts of water. He is weak, lethargic, and confused. The nurse is concerned about seizures.Which electrolyte imbalance is causing the problem?

Hyponatremia

Santos has been without food for almost 2 weeks as a result of digestive problems. He has been started on a meal and is eager to clean his plate. After eating, he experiences joint stiffness and paresthesia of the extremities. Which electrolyte imbalance is causing the problem?

Hypophosphatemia

Which type of intravenous (IV) solution would the nurse anticipate being prescribed to a client with intracellular dehydration related to nausea and vomiting from the flu?

Hypotonic

An 82-year-old woman was brought to the emergency department by her granddaughter. She is a widow and lives alone, although her granddaughter checks on her daily. She has been vomiting for 2 days and has not been able to eat or drink anything during this time. She has not urinated for 12 hours. Physical examination reveals the following: T = 99.6°F (37.6°C) orally; P = 110 beats/min, weak and thready; BP = 80/52 mm Hg. Her skin and mucous membranes are dry, and there is decreased skin turgor. The patient states that she feels very weak. The following are her laboratory results: Sodium 138 mEq/L Potassium 3.7 mEq/L Calcium 9.2 mg/dL Magnesium 1.8 mg/dL Chloride 99 mEq/L BUN 29 mg/dL The nurse recognizes that the patient is displaying symptoms associated with which of the following?

Hypovolemia

The patient reports pain after surgery, ranking it 6 on a scale of 1 to 10. She tells the nurse, "I don't want to be all doped up. My family is coming to visit and I want to be alert enough to visit with them." Which of the following medications would likely be most effective for postoperative pain relief without excessive sedation?

Ibuprofen PO

The nurse is caring for a group of patients on the medical-surgical unit. The most important action the nurse can take in preventing falls is:

Identify those patients who are at risk for falls

The nurse knows that iron deficiency anemia is caused by low levels of iron in the body that can be improved by a diet high in iron. Based on this information, the best nursing diagnosis is:

Imbalanced nutrition: less than body requirements for iron r/t possible Deficient Recall of dietary needs

Which of the following interventions would help to prevent or relieve persistent nausea?

Immediately remove any food that the patient cannot eat.

The postoperative patient returned to the surgical nursing unit at 1:30 p.m. The evening shift nurse receives the report and begins working at 3:30 p.m. How often will the evening shift nurse take this patient's vital signs?

Immediately, then every 30 minutes 2 more times, then hourly

A patient is on strict bedrest for 5 days. During this time, she has not had a bowel movement, although she normally passes stool daily. She describes feeling bloated and uncomfortable. A nursing diagnosis that would best address a patient who is on bed rest is Constipation related to:

Immobility

A woman with a high-risk pregnancy with triplets is in preterm labor; she is on strict bedrest for 5 days. During this time, she has not had a bowel movement, although she normally passes stool daily. She describes feeling bloated and uncomfortable. What information should the nurse give the patient when explaining constipation?

Immobility often causes constipation.

Sarah fell while downhill skiing and fractured her tibia. The bone has a compound fracture and has broken through the skin.Which pain intervention would be most beneficial?

Immobilization

A patient who speaks little English is admitted to the hospital after experiencing severe abdominal pain. Which nursing diagnosis is preferred for this patient?

Impaired Communication

A patient's arterial blood gas results are as follows: pH = 7.30; PCO2 = 40; HCO3 = 19 mEq/L; PO2 = 80. An appropriate nursing diagnosis for the patient is which of the following?

Impaired Gas Exchange

Which nursing diagnosis is written in the correct format when using the NANDA-I taxonomy?

Impaired Skin Integrity related to physical immobility AMB skin tear over sacral area

Which nursing diagnosis is written in the correct format?

Impaired Swallowing related to absent gag reflex

Which expected outcome is best for a patient with a nursing diagnosis of Deficient Knowledge related to new drug treatment regimen?

In 1 week after instructional session, describes the expected actions and adverse reactions of his medications

The nurse has received a prescription to obtain a urinalysis and microscopic analysis. When is the ideal time of the day for the nurse to collect this specimen?

In the morning

he nurse is planning care for a renal patient who is prescribed a diuretic medication. In planning care, what is the most appropriate time of day to administer this medication?

In the morning

Which patient is most likely experiencing positive nitrogen balance? A patient admitted:

In the sixth month of a healthy pregnancy

While assessing a patient, the nurse notes that the patient's nails are excessively brittle. What does this finding suggest?

Inadequate dietary intake

A 2-year-old child is scheduled for a tonsillectomy. When determining the plan of care, the nurse should:

Include the parents or caregivers in the plan of care

Why are leg pumps important in the postoperative period?

Increase peripheral circulation with movement

A patient who has a temperature of 101°F (38.3°C) most likely requires:

Increased fluids

During the day shift, a patient's temperature measures 97°F (36.1°C) orally. At 2000, the patient's temperature measures 102°F (38.9°C). What effect does this rise in temperature have on the patient's basal metabolic rate?

Increases the rate by 35%

The nurse enters a patient's room and notes he is nauseous, vomiting, and experiencing abdominal pain, and has no bowel sounds. She concludes that the patient's symptoms may be associated with a paralytic ileus. In arriving at this conclusion, the nurse has used:

Inductive reasoning

When the nurse enters a patient's room to administer a medication, he calls out from the bathroom, telling her to leave his medication on the bedside table. He reassures her that he will take the medication as soon as he is finished. How should the nurse proceed?

Inform the patient that she will return when he is finished in the bathroom.

Bonita tells the nurse she needs to use the restroom. The nurse cannot find adequate help to get Bonita out of bed so she is placed on a bedpan.

Inhibits

Clay is constipated, so the nurse suggests increasing his water intake to 1 liter per day.

Inhibits

Natasha is recovering from surgery and is constipated from the regular opioid pain medications she receives. The nurse requests high fiber in her diet from the dietitian.

Inhibits

The nurse assists Martha to the restroom and leaves the door open a crack so she can be heard if she needs help.

Inhibits

The nurse has an order to deliver an enema to a constipated client. The nurse enters the room and slides the lunch tray to the side, explaining there is an order for an enema.

Inhibits

A patient comes to the urgent care clinic because he stepped on a rusty nail. What type of assessment would the nurse perform?

Initial focused

Which of the following is the best example of a well-written nursing order?

Insert Foley catheter if patient has not voided within 8 hours.

The nurse is completing her plan of care for a patient with congestive heart failure. In performing a direct-care nursing intervention the nurse will:

Instruct the patient about low sodium and low fat diets

A patient admitted to the cardiac unit is going to the cardiac catheterization lab for a procedure. The patient tells the nurse, "I am so anxious about this. I am afraid the procedure might trigger a heart attack." What is the first action by the nurse?

Instruct the patient prior to the procedure about what he can expect of the procedure.

The nurse is working in an outpatient clinic in her community. Late in the afternoon, three clients come in with suspected pediculosis. Which of the following assessments will the nurse perform?

Integumentary assessment for head lice

Which type of client-centered evaluation is performed at specific, scheduled times?

Intermittent

Before inserting a nasogastric tube, the nurse reassures the client. Reassuring the client requires which type of nursing skill?

Interpersonal

The nurse is caring for a patient with a low hematocrit. Which condition would accurately explain this finding?

Intravascular fluid excess

Which is an appropriate intervention for a client who is blind?

Introduce self when entering the room.

A 65-year-old patient is admitted to the hospital with heart failure. The patient's best friend accompanies her on admission. They have been sharing a home since they each were widowed 3 years ago. Both women have grown children who live out of state. Using the family nursing approach, how can the nurse best intervene?

Involve the friend and children in the patient's care, discharge planning, and home care.

The surgeon orders hourly urine output measurement for a patient after abdominal surgery. The patient's urine output has been greater than 60 mL/hour for the past 2 hours. Suddenly, the patient's urine output drops to almost nothing. What should the nurse do first?

Irrigate the catheter with 30 mL of sterile solution.

A patient has a colostomy in the descending (sigmoid) colon and wants to control bowel evacuation and possibly stop wearing an ostomy pouch. To help achieve this goal, the nurse should teach the patient to:

Irrigate the stoma to produce a bowel movement on a schedule

A patient is scheduled for abdominal surgery tomorrow. While gathering preoperative data, the nurse learns that the patient takes the following medications daily: an anticoagulant, a multivitamin, and vitamin E. The patient reports that he stopped taking the anticoagulant 4 days ago as instructed by the surgeon. He has continued to take the multivitamin and vitamin E. Based on the information given, the nurse notifies the surgeon because she:

Is concerned about the vitamin E

Documentation in home healthcare may take many forms. Some nurses use NANDA-I terminology for diagnoses, whereas others use the Clinical Care Classification (CCC) system. The chief benefit of the CCC system is that it:

Is linked to the OASIS reporting forms required by Medicare

The nurse teaching a patient about ways to regain strength after a period of prolonged immobility advises the patient to seek assistance from a physical therapist. Which type of exercise is performed using specialized apparatuses that use resistance at a constant, preset speed?

Isokinetic

What is the most effective way for a new nurse to influence health-care policy and become involved in legislation on the local, state and national levels?

Joining and becoming involved in a professional nursing organization.

The nurse developed a care plan for a patient to help prevent Impaired Skin Integrity. She has made sure that nursing assistive personnel change the patient's position every 2 hours. In the evaluation phase of the Nursing Process, which of the following would the nurse do first?

Judge whether the interventions achieved the stated outcomes

What is wrong with the following diagnostic statement? "Impaired Physical Mobility related to laziness and not having appropriate shoes." The statement is:

Judgmental

A patient with type 1 diabetes mellitus is admitted with hyperglycemia and associated acidosis. The presence of which alternative fuel in the body is responsible for the acidosis?

Ketones

Which of the following reflects the most accurate use of an etiology?

Knowledge deficit related to incorrect use of walker

When applying heat or cold therapy to a wound, what should the nurse do?

Leave the therapy on each area no longer than 15 minutes.

Which teaching strategy is typically most effective for presenting information to large groups?

Lecturing using audiovisual format

While teaching a session at the local library, the nurse emphasizes that according to the National Weather Service, which of the following is the leading cause of weather-related fatalities?

Lightning strikes

Which factor in a patient's medical history is most likely to prolong the half-life of certain drugs?

Liver disease

A nurse is entering a pharmacy request for patient medication in the patient's electronic health record (EHR) while seated at a computer in the nursing station. A physician approaches her and asks her to access another patient's EHR so that he can look at the patient's laboratory report. Which of the following is the best action for the nurse to take?

Log off the computer before proceeding.

The nursing student is preparing to administer lisinopril to her patient but does not know what lisinopril is used for. What is the most appropriate action by the student to obtain the information?

Look up lisinopril in a medication reference text.

An older patient with newly diagnosed osteoporosis asks the nurse to explain her health problem. Which of the following is the correct description of osteoporosis?

Loss of bone density that increases the risk of fracture

The nurse completes the nutrition assessment for a 14-year-old female with a BMI of 15. What physical assessment finding might suggest bulimia nervosa?

Loss of enamel on teeth

The nurse is caring for a patient with heart failure. The patient has chronic fluid volume excess secondary to ineffective pumping action of the heart. When teaching this patient about fluid and electrolyte balance, which diet is most important for the nurse to explain?

Low sodium

The nurse is caring for a patient with a significant history of hypertension and cardiovascular disease. The nurse would be most interested in the findings of which laboratory results?

Low-density lipoproteins (LDL) and high-density lipoproteins (HDL)

A patient who emigrated from India is admitted to the medical step-down unit with a bowel obstruction. A nasogastric (NG) tube is inserted to decompress her stomach. She asks the nurse whether her daughter can bring in garlic to administer through her NG tube. The nurse tells the patient that she will ask the physician when she makes rounds. This nurse is using the theory developed by which nurse theorist?

Madeline Leininger

A few nurses on a unit have proposed to the nurse manager that the process for documenting care on the unit be changed. They have described a completely new system. Why is it important for the nurse manager to have a critical attitude? It will help the manager to:

Maintain an open mind about the proposed change

Which of the following is the best example of an outcome statement? The patient will:

Maintain oxygen saturation above 92% while performing ADLs each morning

The second-year nursing student is in her clinical rotation on a medical-surgical unit. What is the most appropriate strategy that the student can use to assist her in organizing and prioritizing patient care for the day?

Make a time-sequenced "to do" list for her activities for the day

The nurse has just been assigned to the clinical care of a newly admitted patient. To know how best to care for the patient, the nurse uses the Nursing Process. Which step would the nurse probably undertake first?

Make an assessment

The nurse has scheduled a meeting with a family to assess and assist with improving the family's communication patterns. What is of primary importance for the nurse to focus on during the assessment?

Making careful observations of body language and nonverbal expressions during the meeting

You are caring for a patient with numerous physiological complaints. A family member tells you that the patient is pretending to have the symptoms of a stomach ulcer to avoid going to work. Which somatoform disorder is this patient most likely experiencing?

Malingering

The nurse cares for a patient who is diagnosed with a sexually transmitted infection (STI). The patient is upset and asks the nurse not to share this information with anyone. The nurse explains to the patient that this must be reported to the local Health department based on which regulation?

Mandatory reporting

Esther puts on her call light during the night, telling the nurse that her back aches from being in bed so long and she cannot sleep.Which pain intervention would be most beneficial?

Massage

During a clinic interview, a client states he has been experiencing dizziness upon standing. Which nursing action is appropriate for the nurse to implement?

Measure vital signs with the client supine, sitting, and standing.

Which of the following actions would the nurse prioritize for the patient who is experiencing chronic back pain that interferes with activities of daily living (ADLs)?

Meet with the healthcare team to discuss a pain management plan.

A 52-year-old female comes to the office for her routine yearly physical examination. As part of the nurse's assessment, which of the following principal physical changes in women of this age group is most expected?

Menopause

A client is admitted to the emergency department (ED) in respiratory distress. The arterial blood gases are pH = 7.30; PCO2 = 50; HCO3- = 23 mEq/L. How should the nurse interpret the results?

Metabolic acidosis

A client with impaired renal function is in diabetic ketoacidosis. What acid-base imbalance would be anticipated?

Metabolic acidosis

A client is admitted to the emergency department (ED) in respiratory distress. The results of his arterial blood gases are the following: pH = 7.30; PCO2 = 40; HCO3 = 19 mEq/L; PO2 = 80. The nurse interprets the findings as which of the following?

Metabolic acidosis with normal oxygen levels

A patient had gastric surgery 10 days ago and continues to require gastric suction because of a paralytic ileus. The patient reports tingling in the fingers, has hypertonic reflexes, and has a respiratory rate of 8 breaths per minute that are deep in nature. The nurse recognizes that these symptoms are consistent with which diagnosis?

Metabolic alkalosis

A client underwent abdominal surgery and has a nasogastric tube to suction. There has been a large amount of drainage from the nasogastric tube. The client is disoriented to person, place, and time. ABGs show pH 7.57, PaCO2 37 mmHg, and HCO3- 30 mEq/L. What is the acid-base imbalance?

Metabolic alkalosis, uncompensated

Which describes the body breaking down nutrients into chemical energy and then into usable energy?

Metabolism

The nurse preparing a teaching plan ensures that the information is tailored to the client's life experiences and learning level. These are examples of which right of teaching?

Method

Which client does the nurse recognize as being at greatest risk for pressure ulcers?

Middle-aged adult with quadriplegia

A patient develops urticaria and pruritus 5 days after beginning phenytoin for treatment of seizures. Which type of reaction is the patient most likely experiencing?

Mild adverse reaction

Which are nutrients that are inorganic elements found in nature?

Minerals

Why should the nurse have the patient grasp the right bed rail when turning in bed?

Minimize incision pain

Why should the nurse confirm that the NG tube is secured to the client's nose and gown?

Minimize movement

The nurse receives a prescription to begin a morphine drip for a patient who is to be taken off the ventilator, and to increase the infusion rate as needed to maintain the patient's comfort. The nurse refuses to carry out the order because the morphine will depress respirations and the nurse believes this is equivalent to killing the patient. Which concept best describes what this nurse is demonstrating?

Moral agency

The patient is sitting in a chair at the bedside. The nurse is preparing to remove the patient's artificial eye. What should the nurse ask the patient to do to best position him for this procedure?

Move to the bed and lie down.

A full-spectrum nurse uses a critical-thinking model to organize her thinking when caring for a patient. The nurse realizes she lacks some facts about the patient's pathophysiology, so she makes sure to use a credible source for the information. She considers the alternatives for action, then again looks up some information. Before deciding what to do, she thinks about the patient's family situation. What aspect of a critical-thinking model does this best illustrate? The nurse is:

Moving back and forth between steps, and not thinking sequentially

When making rounds on the night shift, the nurse observes her patient to be in deep sleep. His muscles are very relaxed. When he arouses as the nurse changes the IV tubing, he is confused. What stage of sleep was the patient most likely experiencing?

NREM III

The nurse working on the postpartum unit is preparing a first-time mother for discharge to home. What information should be included in the teaching plan?

Nap frequently during the day when you can.

Why might a healthcare provider choose narrative charting instead of using forms or checklists?

Narrative charting tracks the client's changing health status as it occurs.

The charge nurse in a progressive care unit assigns the care of a patient receiving hemodialysis to a newly hired licensed practical nurse (LPN) without checking to see that the nurse has been determined competent to care for hemodialysis patients. The LPN is in orientation and fails to inform the charge nurse that she does not have experience with this type of patient. The actions of the charge nurse would be considered to be which of the following?

Negligence

Which urinary system structure is considered the functional unit responsible for filtration and water absorption?

Nephron

Which of the following instructions is most important for the nurse to include when teaching a mother of a 3-year-old about protecting her child against accidental poisoning?

Never leave the child unattended around medications or cleaning solutions.

A patient tells you that she has trouble falling asleep at night, even though she is very tired. A review of symptoms reveals no physical problems and she takes no medication. She has recently quit smoking, is trying to eat healthier foods, and has started a moderate-intensity exercise program. Her sleep history reveals no changes in bedtime routine, stress level, or environment. Based on this information, the most appropriate nursing diagnosis would be Disturbed Sleep Pattern related to:

Nicotine withdrawal

A community health nurse is evaluating the current health programs in the community. Which of these outcomes would indicate a healthy community?

Ninety percent of members report adequate access to primary care services.

Which oxygen delivery method can deliver the highest Fio2?

Nonrebreather mask

The patient in the intensive care unit has developed a urinary tract infection related to the indwelling urinary catheter. Which of the following best describes this type of infection?

Nosocomial

The second-year nursing student is in a pediatric clinical rotation in the emergency department. While working one day, a 6-year-old child and mother arrive. The student notices bruises on the child and the mother seems to avoid answering any questions related to the bruises. The most appropriate action by the student is to:

Notify her instructor

When transferring a patient from a hospital to a long-term care facility, which of the following is most helpful in facilitating the patient's planning and emotional adjustment?

Notify the patient and family as much in advance of the transfer as possible

After receiving ibuprofen (Motrin) 800 mg orally for right hip pain, the patient states that his pain is 8 out of 10 on the numerical pain scale. Which action should the nurse take?

Notify the prescriber that the current pain management plan is ineffective.

The nurse is caring for a patient who underwent a bowel resection 2 hours ago. His urine output for the past 2 hours totals 50 mL. Which action should the nurse take?

Notify the provider about the patient's oliguria.

You are a preceptor for a new nursing employee at the local hospital. She needs to access a patient's electronic health record (EHR) to retrieve laboratory results; however, the newly hired nurse has not yet received a computer password. What action should you take?

Notify your supervisor that the new employee needs a password.

Which of the following is the best example of the implementation phase of the nursing process?

Nurse inserts Foley catheter after reporting to physician patient's inability to void.

Who is responsible for evaluating the outcome of a task delegated to the nursing assistive personnel (NAP)?

Nurse who delegated the task

When using the SBAR model to communicate with a physician, what information does the nurse offer first?

Nurse's name, patient's name, and reason for the communication

Which of the following is the most important reason for nurses to be critical thinkers?

Nurses care for clients who have multiple health problems.

Which statement related to prioritizing patient problems is most accurate?

Nurses prioritize problems in order of urgency.

The similarities between the Omaha System and the NANDA-I taxonomy are that both contain which of the following?

Nursing diagnoses expressed in standardized language

The nurse is inserting an indwelling urinary catheter for a female patient. Upon insertion of the catheter the nurse accidently touches the patient's leg and bed sheet with the tip of the catheter. What is the most appropriate action by the nurse?

Obtain a new catheter and reinsert it using sterile technique.

The nurse obtains the following vital signs on an adult patient: T. 100.6°F BP 100/60, HR 110, respirations 36. What is the first action by the nurse?

Obtain a pulse oximetry reading.

A client's axillary temperature is 100.8°F. The nurse realizes this is outside normal range for this client, and that axillary temperatures do not reflect core temperature. What should the nurse do to obtain a good estimate of the core temperature?

Obtain a rectal temperature reading.

Which of the following nursing activities is most reflective of the evaluation phase of the nursing process?

Obtaining patient's blood pressure 30 minutes after administering blood pressure medication

Where is the sense of vision perceived in the brain?

Occipital lobes

Which action should the nurse take when beginning bladder training using scheduled voiding?

Offer the patient a bedpan every 2 hours while she is awake.

To which age group do most hospitalized patients belong?

Older adults

When encouraging a fitness program for healthy older adults, what must the nurse consider?

Older adults at risk for falling should do activities that maintain or improve balance.

A 78-year-old couple is moving out of state to be closer to family members. Which of the following residences is most appropriate for this couple?

One-level living area condominium with good lighting inside and outside

An alert, oriented, and competent frail older adult man has been told that he is dying and has asked to have a DNAR (AND) prescription put on his chart. The patient's family does not agree with his decision and asks the healthcare team to ignore the request. After a great deal of discussion among the physician, nurse, and family, they are no closer to resolution of the conflict. The nurse asks the hospital chaplain to come and help the family and the team understand each other's opposing views. Which step of the MORAL model does this illustrate?

O—Outline the options

Identify the type of surgery a terminally ill patient will undergo if the purpose is removal of tissue to relieve pain.

Palliative

The nurse is planning a health promotion class for young adult women. What topic would be most important for the nurse to include for this group?

Pap test every 2 or 3 years

The nurse assesses a patient's abdomen 4 days after abdominal surgery and notes that bowel sounds are absent. This finding most likely suggest which postoperative complication?

Paralytic ileus

What are patterns of waking behavior that appear during sleep known as?

Parasomnias

The new mother who just gave birth tells the nurse, "I don't know anything about babies, so I want you to teach me everything you can to help me be a good mother." What nursing diagnosis would be most appropriate for this patient? Readiness for Enhanced:

Parenting

A patient with quadriplegia presents to the outpatient clinic with an ischial wound that extends through the epidermis into the dermis. When documenting the depth of the wound, how would the nurse classify it?

Partial-thickness wound

Which course of action taken by her patient with osteoporosis would allow the nurse to know that her teaching was effective?

Participating in an aerobic barbell strength class at the gym three times a week

What type of immunity is provided by intravenous (IV) administration of immunoglobulin G?

Passive

Which is the most commonly reported incident in hospitals?

Patient falls

Assuming that all are accurate, which documentation about a patient's level of consciousness is best?

Patient responds to tactile stimulation; falls back to sleep immediately after tactile and verbal stimulation are stopped.

The nurse is caring for a patient who suffered a stroke and now has expressive aphasia. The nurse is having a difficult time communicating and the patient is becoming angry and frustrated. In developing the plan of care, what is the most appropriate outcome for this patient?

Patient will use alternative methods of communication.

A patient had a bowel resection 5 days ago. Which request by the patient might alert the nurse that the patient has a history of substance abuse?

Patient-controlled analgesic

Nursing codes of ethics support which of the following?

Patients have the right to dignity, privacy, and safety.

A patient had a hiatal hernia repair earlier today and is now in the postanesthesia care unit (PACU). The family asks the nurse why the patient is in the PACU rather than back in his room on the postsurgical unit. The nurse should inform the family that:

Patients recover from the effects of anesthesia in the PACU and then return to the postsurgical unit for further care

The nurse is working at a hospice organization in her area. Which of the following best describes the patients for whom she will be caring?

Patients who are terminally ill and their family members

The nurse is planning a breast examination class for a group of women at a community health fair. In planning the class, what is most important for the nurse to consider in preparation for her class?

Patients who perform breast self-examinations should be trained in proper technique to avoid false-negative findings.

A registered nurse forgot to put the siderails up for a confused patient. The patient fell out of bed and fractured his hip. The patient sues and wins a judgment (award) for $2 million. The nurse has an occurrence policy with double limit coverage of $3 million/$10 million that covered the time period when the incident occurred. The statement that best describes the nurse's situation is that her insurance policy will do which of the following?

Pay $2 million

A nurse researcher is designing a research project. After identifying and stating the problem, the nurse researcher clarifies the purpose of the study. Which step in the research process should she complete next?

Perform a literature review

Which finding would the nurse expect to note when assessing a client with right-sided heart failure?

Peripheral edema

Which condition is the result of loss of higher cerebral function?

Persistent vegetative state (PVS)

A patient is receiving an IV infusion of lactated Ringer's solution and 40 mEq of KCl at 100 mL/hr. When assessing the IV site, the nurse notes swelling, erythema, and warmth. There is a palpable cord along the vein, and the infusion is sluggish. The patient is complaining of pain at the site. The nurse would recognize these findings to be consistent with which of the following?

Phlebitis

Which electrolytes are inversely related to each other?

Phosphorous and calcium

The nurse checks a patient's pupils using a penlight. Which receptors is the nurse stimulating?

Photoreceptors

Dunn believes that an individual's state of health should be evaluated in the context of the person's environment. This approach illustrates that:

Physical environment, family, and social support may help or hinder the health status of an individual

A nurse is caring for a 22-year-old who has lost his or her leg due to a motor vehicle crash. The client is very withdrawn and is not interested in pursuing physical therapy. The client says, "What's the point? I will never have a normal life now." The nurse knows the client is experiencing which type of loss?

Physical loss

After suffering an acute myocardial infarction, a patient attends cardiac rehabilitation. This will help to gradually build his exercise tolerance. According to Maslow's Hierarchy of Needs, cardiac rehabilitation most directly addresses which need?

Physiological

Which of the following would be a typical priority for an adolescent? Being:

Picked to be on the soccer team

The nurse is instructing a client how to appropriately dress an infant in cold weather. Which of the following instructions would be most important for the nurse to include?

Place a cap on the head.

Sallie Jo, an older adult, is being admitted with confusion. What actions should the nurse take in preparing for her stay?

Place her bed in the lowest position.

How should the nurse dispose of a contaminated needle after administering an injection?

Place the needle in a specially marked, puncture-proof container.

Which action should the nurse be sure to take when preparing a patient for a bed bath?

Place the nurse call device within reach.

The nurse documents a patient's radial pulse rate as 120 beats/min and regular. One hour later, the nurse rechecks the pulse and it is irregular at 120 beats/min. What is the most appropriate nursing action?

Place the patient on a cardiac monitor.

Which intervention is helpful when caring for a patient with impaired vision?

Place the patient's eyeglasses within easy reach.

How should the nurse dispose of the breakfast tray of a patient who requires airborne isolation?

Place the tray in a special isolation bag held by a second healthcare worker at the patient's door.

The nurse is planning a teaching workshop at the local community center for a group of 66-year-old men and women. What information is most important to include at the workshop?

Planning leisure activities and exercise

The nurse is working on an orthopedic unit in the local hospital. While assessing her patient the patient states, "Ever since we had the earthquake in California I can't sleep for fear of another one happening during the night, and I just keep having flashbacks of the earthquake." The nurse knows that these patient statements are most consistent with:

Post-traumatic stress disorder

A patient with a history of hypertension and rheumatoid arthritis is admitted for surgery, a colon resection, for colon cancer. Which integrated plan of care (IPOC) would be most appropriate for the nurse to implement?

Postoperative colon resection

A patient and his wife are 2 years from retirement when he is diagnosed with lung cancer. Although with delayed childbearing, developmental stages can vary among families, which typical stage of family development is this couple likely experiencing?

Postparental family

A patient is admitted for hip surgery. The patient usually takes the following medications daily: an anticoagulant, a multivitamin, and vitamin E. He stopped taking his anticoagulant 4 days ago as instructed by his surgeon, but has continued to take the multivitamin and vitamin E. An important collaborative problem or nursing diagnosis for this patient is which of the following?

Potential complication: increased bleeding

Which intervention should the nurse take first to promote micturation in a patient who is having difficulty voiding?

Pour warm water over the patient's perineum.

The nurse talks to a patient about the health risks related to smoking and the patient says, "My husband has been nagging me about that, but I really don't smoke all that much and don't see it as much of a problem in my case." Within what transtheoretical stage of change would the nurse classify this patient as operating?

Precontemplation

A 48-year-old patient comes to the physician's office complaining of diminished near vision, which the nurse confirms with testing. She should document this finding as:

Presbyopia

The nurse would question a prescription for application of cold therapy to which patient? The patient with a:

Pressure ulcer

The Joint Commission's national Speak Up® campaign encourages patients to become active and informed participants on the healthcare team. The goal is to:

Prevent healthcare errors

Why should space be left between the leg and the sleeve when applying a knee-high cuff?

Prevent over compression

Why should stockings be kept free of wrinkles and bunching?

Prevent skin breakdown

Why is it important for the nurse to turn off the suction before emptying the suction container?

Prevent suction flow

Why should a patient remain supine for 15 minutes before compression stockings are applied?

Prevent trapping of pooled blood

The nurse is performing preoperative teaching for a client who is scheduled for surgery in the morning. The client does not at present have any respiratory problems. The nurse's teaching plan includes coughing and deep-breathing exercises. Which type of nursing intervention is the nurse performing?

Prevention

The nurse is informing a client of the need for a new intravenous (IV) line to be inserted. The client begins crying and shaking uncontrollably and says, "I can't go through this again!" Which factor is influencing this pain?

Previous experience

The nurse has a new order to apply antiembolism stockings. At what point should that occur?

Prior to surgery

The community health nurse has gathered data about the community. She identifies many weaknesses in the community health systems that contribute to poor health outcomes. What should be her next step?

Prioritize the list of problems.

The nurse is assisting a client in the emergency department who needs to use the restroom for a bowel movement. Which option is best?

Private restroom

A student nurse makes the following comments to her preceptor: "I love getting information from the chart. Everything related to the patient's problem is together and addressed by various members of the healthcare team." The student nurse has been introduced to which type of charting system?

Problem oriented

The preoperative nurse is assessing a client who is having surgery in one hour. Which finding warrants immediate health-care provider notification?

Productive cough and fever

The spouse of a patient recently diagnosed with cancer reports feeling anxious and is having trouble sleeping at night despite feeling tired. The spouse says sleep was never previously a problem. What type of interventions would be first priority for the spouse?

Promote relaxation.

Jeremy has a digestive disorder that causes a lot of gas. He is in a semiprivate room and mentions how disturbing it must be for his roommate. The nurse sprays some odor-reducing product and leaves it with Jeremy to use as needed.

Promotes

Knute is in a care center and tells the nurse he has not had a bowel movement for 2 days. The nurse suggests they go for a walk later.

Promotes

Stanley is recovering from knee surgery and has not had a bowel movement for 3 days. The nurse places him on the bathroom toilet rather than having him use the bedside commode or a bedpan.

Promotes

What is the function of antidiuretic hormone when released in the alarm stage of the general adaptation syndrome?

Promotes fluid retention by increasing the reabsorption of water by kidney tubules

Which behavior by the mother is most likely to help the infant to develop trust?

Promptly responding to the infant's crying

group of pediatric nurses accepts an international assignment in an underdeveloped country. The nurses are informed that they will be caring for many children with kwashiorkor. The nurses will create a care plan focusing on which primary nutrient for these children?

Protein

An insulin-dependent diabetic patient tells the nurse that she has been giving herself injections in the same location in her right thigh for the past several months because it is easier. What is the nurse's best action?

Provide patient teaching on rotating injection sites.

At the end of a 12-hour shift, the nurse gives a verbal report to the oncoming nurse. This face-to-face reporting, using the acronym "CUBAN," does which of the following?

Provides a guide for the nurse's report to the oncoming nurse

Which pain management task can be safely delegated to nursing assistive personnel?

Providing a therapeutic back massage

The Health Information Technology for Economic and Clinical Health (HITECH) encouraged implementation of electronic health records (EHR) by what means?

Providing incentive payments to facilities that converted to EHRs

What anatomical feature makes women more prone to urinary tract infections than men?

Proximity of the urethra to the vagina and anus

Ralph has degenerative joint disease and experiences pain with any physical activity, including waking. He is irritable and wants to be left alone to sleep all the time. Which nonverbal response is being demonstrated?

Psychological pain response

Should a bioterrorism event occur, what factor is most important in minimizing the effects of such an event?

Rapidly recognize unusual disease patterns and detect the presence of unusual infectious diseases.

A 60-year-old male attends a smoking cessation class. He tells the nurse, "Even though I smoke, I don't smoke around children, in my car, or in my house" Which defense mechanism is this male exhibiting?

Rationalization

The nurse is caring for a patient scheduled for repair of a torn rotator cuff. The nurse understands that this surgery will be classified as:

Reconstructive, minor, elective

What is(are) the primary benefit(s) of computer physician order entry (CPOE)?

Reduced medication errors

During patient rounds with the multidisciplinary team, the nurse expresses disagreement with the type of medication prescribed for her patient hospitalized for renal failure. What is the likely result of the nurse's speaking up?

Reduces the opportunity for inadvertent error in clinical judgment

Which member of the healthcare team typically serves as the case manager?

Registered nurse

An 80-year-old patient fell and fractured her hip and is now in the hospital. Before the fall, she lived at home with her husband and managed their activities of daily living very well. The goal is for the patient to recover from the injury and return to her home. The hospital is ready to discharge her because she has exceeded the recommended length of stay in a hospital. However, she cannot walk or care for herself yet, and she will require lengthy physical therapy and further monitoring of her medications and her physical and mental status. To which type of facility should she be transferred?

Rehabilitation center

The nurse is using electronic care planning. He enters the patient's nursing diagnosis into the computer and chooses desired outcomes. He has validated his data, diagnosis, and goals. When he considers the list of interventions that the program generates, he sees that none of them fits this patient's individual needs. What should the nurse do?

Reject them all and type in appropriate interventions.

The nurse has started to infuse the first of two units of packed red blood cells (prbc) on her patient. What is the nurse's next best action?

Remain with the patient for the first 15 minutes of the infusion.

While donning sterile gloves, the nurse notices the edges of the glove package are slightly yellow. The yellow area is more than 1 inch away from the gloves and only appears to be on the outside of the glove package. What is the best action for the nurse to take at this point?

Remove gloves from the sterile field and use a new pair of sterile gloves.

A nurse is teaching a group of mothers about first aid. Should poison come in contact with their child's clothing and skin, which action should the nurse instruct the mothers to take first?

Remove the contaminated clothing immediately.

A patient is admitted with high BUN and creatinine levels, low blood pH, and elevated serum potassium level. Based on these laboratory findings the nurse suspects which diagnosis?

Renal Failure

The nurse takes a telephone order from a primary care provider for 40 mEq potassium chloride in 100 mL of sterile water for injection to be infused over 4 hours. Which action must the nurse take to ensure the accuracy of the order?

Repeat the order to the prescriber even if she believes she understood the order correctly.

The nurse notes that a patient's indwelling urinary catheter tubing contains sediment and crusting at the meatus. Which action should the nurse take?

Replace the indwelling urinary catheter.

Which of the following patient goals is most appropriate when managing the patient dying of cancer? The patient will:

Report or demonstrate satisfactory pain control

Which of the following is the most valid criterion for determining the status of a patient's anxiety at discharge? The patient:

Reports that he feels more relaxed today

What is the correct method for turning an adult patient who recently sustained a spinal cord injury?

Request help from another nurse to perform the logrolling technique.

A patient who speaks only French was admitted to the hospital after a motor vehicle accident. Assuming that the nurse does not speak French, what is the best way to communicate with this patient?

Request the services of a hospital translator.

Which of the following characteristics do the various definitions of critical thinking have in common? Critical thinking:

Requires reasoned thought

Which of the following best describes an assisted living facility (ALF)?

Residence that provides 24-hour supervision and assistance with scheduled and unscheduled activities

A nurse has been asked to design an exercise program with the goal of increasing a client's muscular strength and endurance. Which exercise program would specifically focus on meeting that goal?

Resistance training

A client is admitted with shortness of breath, pyrexia, and a productive cough with yellow-green sputum. Upon examination, crackles and wheezes can be heard in the lower lobes; he has a tachycardia and a bounding pulse. Measurement of arterial blood gas shows pH 7.3, PaCO2 68, HCO3- 28, and PaO2. How would the nurse interpret this?

Respiratory acidosis, partially compensated

A client comes to the hospital after falling. She has tachycardia and is tachypneic. Painkillers were administered to lessen her pain, and 30 minutes later she states that she is still in pain and is now experiencing muscle cramps, tingling, and paresthesia. Arterial blood gas reveals pH 7.6, PaCO226 mm Hg, and HCO3- 25 mmol/L. What is the acid-base imbalance?

Respiratory alkalosis, uncompensated

The nurse is caring for a patient with a medical diagnosis of hypernatremia. The following prescriptions are written in the client's electronic health record. Which one should the nurse question?

Restrict oral intake to 900 mL every 24 hr.

The nurse identifies a client's risk for fluid volume excess. Which intervention should be included in the plan of care?

Restrict the client's sodium in the diet.

Which structure within the brain is responsible for consciousness and alertness?

Reticular activating system

After obtaining a full set of vital signs, the nurse assesses the client's fifth vital sign as a 7 on a scale of 1 to 10 (or 7/10). Which action by the nurse is most appropriate?

Review the client's records to determine the last time he received pain medication.

A client is admitted to the hospital with an acute episode of chronic obstructive pulmonary (lung) disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations and has recorded the diagnosis and appropriate goals on the care plan. When selecting nursing interventions, what should the nurse do first?

Review the problem and etiology of the nursing diagnosis.

What is the most essential action by the nurse prior to delegating the administration of an intravenous (IV) medication to a licensed practical nurse (LPN)?

Review the state's nurse practice act for LPN scope of practice.

Based only on Maslow's Hierarchy of Needs, which nursing diagnosis should have the highest priority?

Risk for Aspiration

Physiological changes associated with aging place the older adult especially at risk for which nursing diagnosis?

Risk for Falls

The home health nurse is developing a plan of care for her patient with a visual impairment. What is the priority nursing diagnosis for this patient?

Risk for Falls

The nurse volunteers to work at the annual summer 20-mile marathon in her community. In planning for the event, the nurse knows that which of the following nursing diagnoses is most important to include in the plan?

Risk for Imbalanced Body Temperature

A client's epidermis has insufficient melanin. Which nursing diagnosis is appropriate?

Risk for Impaired Skin Integrity

A man was involved in a motor vehicle accident yesterday. He is to be sedated for more than 2 weeks while breathing with the assistance of a mechanical ventilator. Which of the following would be an appropriate nursing diagnosis for him at this time?

Risk for Impaired Skin Integrity related to immobility

The nurse is caring for a patient who has had an indwelling urinary catheter inserted for the past 5 days. In reviewing and revising the plan of care, what is the most important nursing diagnosis for this patient?

Risk for Infection

Which nursing diagnosis has the highest priority for a patient with impaired tactile perception?

Risk for Injury

Identify the most appropriate nursing diagnosis for promoting the safety of a frail, elderly patient after hip replacement surgery who also has a history of emphysema.

Risk for Injury related to medical condition

The nurse admits a patient who is scheduled for surgery tomorrow morning. The nursing admission assessment indicates that the patient is mildly anxious about the procedure, does not drink alcohol or smoke, is married with two children, and is allergic to kiwi, avocados, and penicillin. The nurse identifies the priority nursing diagnosis for this patient as:

Risk for Latex Allergy Response

The nurse is caring for a patient with a history of postural hypotension. She obtains a blood pressure reading on her patient of 130/80 lying and 100/60 standing. What is the most appropriate nursing diagnosis for this patient?

Risk for falls

The nurse admits a patient to the postoperative unit following gastric bypass surgery for weight loss. Based on the patient's history, the nurse determines that the priority nursing diagnosis for this patient is:

Risk for infection

The school nurse at a local elementary school is performing physical fitness assessments on the third grade children. When assessing students' cardiorespiratory fitness, the most appropriate test is to have the students:

Run a mile without stopping, if they can

After assessing a client who has just been weaned from the ventilator, the nurse determines the client is not yet able to ambulate and does not follow the physician's order. What protects the nurse from being terminated or disciplined for not following orders?

Safe harbor laws

What is the highest priority of the perioperative nurse's role?

Safety

The nurse researcher decides to conduct a research study on the association between aging male populations and their development of prostate cancer. She uses a sample size from her community of 50 males aged more than 80 years, a quantitative research design, and finds that many of these participants developed cancer after the age of 80. She reports in her findings: All male patients over the age of 80 years old will most likely develop prostate cancer. Based on the information given above, what is flawed in this research?

Sample size is too small to make a generalization.

or an elderly client who is experiencing chronic nausea and weight loss, which laboratory result would the nurse recognize as being most consistent with a diagnosis of Imbalanced Nutrition: Less Than Body Requirements?

Serum albumin of 3.2 g/dL

An alert, oriented, and competent frail older adult man has been told that he is dying and has asked to have a DNAR (AND) prescription put on his chart. The patient's family does not agree with his decision and asks the healthcare team to ignore the request. The healthcare team does not comply with the family's wishes, and after several days the family takes the matter to court. The court sides with the family and orders the healthcare team to remove the DNAR (AND) prescription. This is an example of which of the following?

Settlement of an issue by force

Which scenario puts a person at highest risk for experiencing complicated grief?

Several losses in a short period of time

The nurse is supervising a student nurse preparing a client for surgery. Which action made by the student nurse requires intervention by the nurse?

Shaving the hair from the surgical site with a razor

A hospital that is interested in purchasing IV infusion pumps organizes a group of nurses to evaluate pumps provided by a variety of vendors. Which type of group has been organized?

Short term

The nurse is caring for an elderly woman with dementia who is frightened in the hospital room. Which is the best action by the nurse to communicate empathy and compassion?

Shut the patient's door in the hallway if there is noise or loud talking.

With which type of bowel diversion is the client most likely to have control over bowel elimination and not need to wear an appliance?

Sigmoid colostomy

What type of indwelling catheter is most suitable for long-term use?

Silicone catheter

During advanced cardiac life support (ACLS) training, a nurse performs defibrillation using a mannequin. Which teaching strategy is being employed?

Simulation

The wife of an elderly patient begins crying after she is informed that he is has a terminal illness. Which intervention by the nurse is best?

Sit quietly with the patient's wife while she composes her thoughts.

Which of the following is a nonverbal behavior that enhances communication?

Sitting down to speak with the patient

Which set of topics makes up a handoff report given in a recommended format?

Situation-background-assessment-recommendation (SBAR)

The nurse is helping the patient to perform leg exercises after surgery to prevent thrombophlebitis. Which type of muscle is the patient using for these exercises?

Skeletal

What is the difference between skilled care and custodial care?

Skilled care focuses on short-term rehabilitation, while custodial care focuses on activities of daily living and other daily needs clients would typically do themselves.

The nurse identifies the nursing diagnosis Urinary Incontinence (Total) in an older adult patient admitted after a stroke. Urinary Incontinence places the patient at risk for which complication?

Skin breakdown

Which assessment provides an estimate of a person's body fat content?

Skinfold measurements

The nurse is caring for a patient with gastroenteritis who has been vomiting for 48 hours. A family member of the patient asks the nurse, "Why is he breathing that way?" What is the nurse's most accurate response after explaining the meaning of pH? "He is breathing

Slow and shallow to try to retain carbon dioxide to decrease his pH"

Which action should the nurse take if it is discovered that an IV infusion has been running too fast for the past hour?

Slow the infusion and assess for fluid volume excess.

The nurse will teach the community-based client that the most common cause of injury related to a house fire is/are:

Smoke inhalation injury

Which healthcare worker should the nurse consult to counsel a patient about financial and family stressors impacting healthcare?

Social worker

A patient is brought to the emergency department experiencing leg cramps. He is irritable, his temperature is elevated, and his mucous membranes are dry. Based on these findings, the patient most likely has excess levels of which mineral?

Sodium

Which electrolyte will most impact fluid status in the body?

Sodium

The nurse has been teaching a parent about stimuli to develop her infant's auditory nervous system. Which behavior by a parent toward the child provides evidence that learning occurred?

Speaking

Which of the following is particularly valuable in helping a patient with a terminal illness maintain a sense of self?

Spirituality

According to John Bowlby's phases of grief, which client action indicates the yearning and searching phase of grieving?

Spraying the deceased person's cologne on his or her pillow.

The nurse conducts a class on health promotion for a group of young adults. Which of the following comments would indicate the teaching was effective? "I will:

Start doing testicular self-exams"

Which statement below is the best example of high-quality nursing documentation?

Started on solid foods. Ate 75% of dinner. No complaints of any nausea or vomiting.

A nurse is caring for a client who is confused. Which would be the most appropriate way to approach bathing the client?

State "Time for a bath."

In the United States, each state enacts its own nurse practice acts. Which agency is responsible for nurse practice acts?

State Board of Nursing

Which organization can require nurses to take continuing education courses as a condition of licensure renewal?

State Board of Nursing

The nurse is planning care for a patient. She is using a standardized care plan for Impaired Walking related to left-side weakness. Which of the following activities will the nurse perform when individualizing the plan for the patient?

Stating the frequency for ambulation

A patient in the emergency department is angry, yelling, cursing, and waving his arms when the nurse comes to the treatment cubicle. Which action(s) by the nurse is/are advisable?

Stay between the patient and the door while keeping the door open.

A patient's vital signs prior to a blood transfusion were: T = 97.6°F (36.4°C); P = 72 beats/min; R = 22 breaths/min; and BP = 132/76 mm Hg. Twenty minutes after the transfusion was begun, the patient began complaining of feeling "itchy and hot." The nurse discovered a rash on the patient's trunk. Vital signs were T = 100.8°F (38.2°C); P = 82 beats/min; R = 24 breaths/min; BP = 146/88 mm Hg. Based on these findings, what is the priority intervention?

Stop the blood transfusion immediately.

The nurse is checking the gastric aspirate for the patient receiving tube feedings. She notes the 200 mL of pale yellow and cloudy fluid with a pH of 7.3. Which action should she take?

Stop the feeding immediately; then notify the prescribing provider.

The nurse is performing a colostomy irrigation on a male client. During the irrigation, the client begins to complain of abdominal cramps. What is the appropriate nursing action?

Stop the irrigation temporarily.

The nurse initiates a transfusion of packed red blood cells to a client. Ten minutes later, the client develops fever, chills, shortness of breath, and a heart rate of 120 beats per minute. What should be the nurse's first intervention?

Stop the transfusion immediately.

The nurse is performing an otoscopic examination on an adult patient. She has the patient tilt his head to the side not being examined and looks into the ear canal to make sure a foreign body is not present. Which step should she perform next?

Straighten the ear canal by pulling the helix up and back.

The nurse is planning a health promotion class for adolescents. The presentation is too long. Which topic would be least important and therefore appropriate for the nurse to delete?

Stranger danger

What is the most common cause of infectious pharyngitis?

Streptococcal pyogenes

An overweight client wants to lose weight. What is one realistic goal that the client should understand and set for himself or herself?

Strive to burn at least 500 to 1000 calories more than consumed each day.

The nurse notes ptosis in a patient who just arrived in the emergency department. The nurse quickly triages the patient because she knows that this finding, along with other symptoms, might suggest:

Stroke

While addressing a community group, the nurse explains the importance of replacing saturated fats in the diet with mono- and polyunsaturated fats. She emphasizes that doing so greatly reduces the risk of which complication?

Stroke

A community health nurse prepares for a new assignment. She has been assigned census tracts 131 and 132. This large area crosses the border of two towns and includes 4,000 people. What components of the community must the community health nurse assess prior to beginning her new assignment?

Structure of the tracts, effectiveness of the community, and current status

The nursing staff on the surgical unit complains to the manager that they do not have enough time to complete all wound care and dressing changes. What is the manager's most appropriate action to take?

Suggest a continuing quality improvement committee to assess the issue

A patient with diarrhea is incontinent of liquid stool. The nurse documents that he now has excoriated skin on his buttocks. Which finding by the nurse led to this documentation?

Superficial layers of skin were absent.

A participant in a research study informs the nurse researcher that he has decided to withdraw from the study citing personal reasons. The most appropriate action by the researcher is to:

Support the participant in his withdrawal from the study

The nurse caring for a fussy newborn uses which of the following interventions to calm the baby and reduce sensory overload?

Swaddling the baby tightly

A patient with Raynaud's disease receives no symptomatic relief with diltiazem (Cardizem). Which surgical intervention might be a treatment option for this patient to help provide symptomatic relief?

Sympathectomy

A patient prescribed an NSAID, naproxen (Aleve, Naprosyn), for treatment of arthritis reports stomach upset. What should the nurse instruct the patient to do?

Take the medication with food.

Which of the following is an example of an ongoing assessment?

Taking the patient's temperature 1 hour after giving acetaminophen (Tylenol)

To establish a trusting relationship with a client, the nurse will focus on:

Taking time to get to know the patient

A patient was involved in a motor vehicle accident that resulted in multiple traumatic injuries. He was hospitalized for 8 days in the intensive care unit and 3 days on the surgical floor. He has been discharged home with home health support. Identify the primary goal of his home care.

Teach the patient and family how to provide care.

The patient is scheduled for an outpatient cholecystectomy (gall bladder removal) in 2 weeks. Based on the patient's history, the nurse includes which of the following in the preoperative plan of care?

Tell the patient to inform the surgeon of allergies and chronic health conditions.

The nurse is caring for a critically ill patient with a severe midbrain injury involving the hypothalamus. Which vital sign is most critical for the nurse to monitor closely for this patient?

Temperature

Which skin assessment finding would cause the nurse to suspect dehydration in a middle-aged patient admitted to the hospital with traveler's diarrhea?

Tenting

A client has been referred to hospice for end-of-life care. What type of care is this considered?

Tertiary care

A patient has a contaminated right hip wound that requires dressing changes twice daily. The surgeon informs the nurse that when the wound "heals a little more" he will suture it closed. The nurse recognizes that the surgeon is using which form of wound healing?

Tertiary intention

A 55-year-old man suffered a myocardial infarction (heart attack) 3 months ago. During his hospitalization, he had stents inserted in two sites in the coronary arteries. He was also placed on a cholesterol-lowering agent and two antihypertensives. What type of care is he receiving?

Tertiary prevention

Which describes the glomerular filtration rate?

The amount of filtrate formed by the kidneys per minute

A client blames recent weight gain on his or her metabolism. Which is the best information that the nurse can provide to the client about how metabolism works?

The body converts food into complex forms of chemical energy and then into usable energy; therefore, extra food intake must have equal energy exertion in order to not gain weight.

The nurse receives hand-off report on each of these clients. Who is at the greatest risk for fluid volume excess?

The client with heart failure

Effective delegation is a vital part of the nurse's responsibilities. What factor should guide the nurse to correctly delegate a nursing task?

The education and experience of the delegatee

Which of the following statements best describes how normal voluntary urination occurs?

The external urethral sphincter contracts to force urine out of the bladder.

Which type of pain assessment tool rates pain on a scale of 0 to 10?

The numerical rating scale

The nurse believes that abortion is wrong, but applies the MORAL model and decides that caring for patients following an abortion is her ethical duty. When evaluating the effectiveness of the nurse's decision process, what finding would indicate the nurse made the best choice?

The nurse believes quality care was delivered and feels satisfied with the decision.

In states where assisted suicide is legal, what is the role of the nurse?

The nurse does not participate in any way.

The nurse faces a true ethical dilemma and uses several strategies for resolving the issue. What is the likely outcome?

The nurse will nevertheless probably not be comfortable with any course of action, regardless of the strategy, model, or type of reasoning used.

In which of the following circumstances might the nurse defer obtaining informed consent for care and treatment of a patient?

The patient is brought to the emergency department in cardiac arrest; no family is present.

When teaching a patient about the healing process of an open wound after surgery, which of the following points would the nurse make?

The patient will have more scar tissue formation than there would be for a wound closed at surgery.

An 87-year-old patient has just been diagnosed with cancer. Her durable power of attorney names her son as her surrogate decision maker. He arrives at the patient's bedside to discuss treatment options with her. The patient is alert and oriented. Her son tells you that he does not want her to receive any treatment (chemotherapy) because of the side effects and her age. The patient tells you that she wants to try the treatment. Which decision should be followed by the nurse?

The patient's

Which of the following is a criticism of standardized nursing diagnoses developed by NANDA-I?

There is little research to support nursing diagnosis labels.

What do critical thinking and the Nursing Process have in common?

They are both thinking methods used to solve a problem.

The student nurse asks the provider if she will prescribe an indwelling urinary catheter for a hospitalized patient who is incontinent. The provider explains that catheters should be utilized only when absolutely necessary because:

They are the leading cause of nosocomial infection

What do the nursing assessment models have in common?

They assess and cluster data into model categories.

The nurse is discussing ways to treat functional incontinence with a group of older adults in a senior citizens center. Which intervention would be most appropriate for the nurse to include in the presentation?

Timed voiding

A patient admitted with an acute exacerbation of chronic obstructive pulmonary disease has a nursing diagnosis of Activity Intolerance. Which type of bath is preferred for this patient?

Towel bath

What could potentially occur if a client takes Vitamin A, D, E, and K supplements daily?

Toxicity

Which type of cutaneous pain control would best benefit a client who is afraid of needles?

Transcutaneous electrical nerve stimulator (TENS)

Which is the process of nociceptors becoming activated by the perception of mechanical, chemical, and thermal stimuli?

Transduction

A 32-year-old with a high spinal cord injury has been admitted to the hospital for antibiotic therapy to treat pneumonia. He lives independently and has developed strong upper-body strength to maximize his independence. Which transfer device should be used when transferring him from the bed to his wheelchair?

Transfer board

Which statement accurately describes delegation?

Transferring authority to another person to perform a task in a selected situation

In which process do peripheral nerves carry the pain message to the dorsal horn of the spinal cord?

Transmission

The nurse enters a room to find the client sitting up in the chair, crying. The nurse best displays a critical-thinking attitude, as well as a caring attitude, by:

Trying to determine the reasons for the client's crying

The nurse is teaching the patient about foods that promote sleep versus those that may disrupt sleep. What diet chosen by the patient demonstrates understanding of foods that promote sleep?

Turkey fettuccini, whole wheat bread, and a glass of milk

The nurse is caring for a patient who underwent abdominal surgery 24 hours ago and has a nasogastric tube for intermittent suction. How should the nurse proceed when performing an abdominal assessment on this patient?

Turn off the suction before auscultating bowel sounds.

The postoperative patient is admitted to the postanesthesia care unit (PACU) with an oral airway in place, an indwelling urinary catheter, IV fluid infusing via two different sites, and a Jackson-Pratt drain pinned to the gown near the wound dressing. What is the nurse's priority action after the patient is moved to the bed?

Turn the patient's head to the side.

The nurse planning the care of a frail, malnourished, immobile patient recognizes which of the following as the best treatment to protect the patient's integument?

Turning the patient at least every 2 hours

A medical provider has prescribed milk of magnesia (magnesium hydroxide) 30 mL, PO bid. Here bid means:

Two times every day

After sustaining a stroke, the patient lacks attention to the right side of his body. Which nursing diagnosis best describes the patient's problem?

Unilateral Neglect

A patient hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure area on her coccyx measuring 5 cm by 3 cm. The area is covered with 100% eschar. What would the nurse identify this as?

Unstageable pressure ulcer

When teaching a client how to use a peak flow meter at home, what should be done if the reading falls within the yellow marker of the meter?

Use a fast-acting bronchodilator.

A patient has difficulty taking liquid medications from a cup. How should the nurse administer the medications?

Use a needleless syringe to place the medication in the side of the mouth.

Which instruction by a registered nurse should the student nurse clarify with her clinical instructor? "When taking off the provider's orders, you should:

Use apothecary units—instead of metric units"

The nurse is planning to use guided imagery for a client who reports severe pain related to rheumatoid arthritis. How would the nurse perform this intervention?

Use descriptive words, music, and thoughts to elicit relaxation.

The nurse is talking to a class of children, aged 9 to 11 years. For this age group, it would be most important for the nurse to discuss:

Use of seat belts and safety equipment

Which nursing intervention is most helpful for a client with Alzheimer's disease who has cognitive impairment?

Use reminiscence to help the client recall memories and maintain social interaction

The nurse attempts to transfer a totally dependent patient from a stretcher to a bed. What is the best step to reduce the musculoskeletal risk factors?

Use transfer roller sheet when transferring.

A patient experiences expressive aphasia after a stroke. Which expected outcome is appropriate for this patient?

Uses alternative methods of communication

A surgeon refused a patient's request to restart a patient's total parenteral nutrition (giving nutrition through the intravenous route) because he believed that a greater good would be achieved by not using medical resources to prolong the life of a terminally ill patient when the resources could be used for other patients. Which ethical theory best explains the surgeon's rationale?

Utilitarianism

A patient sustains a laceration of the thigh in an industrial accident. Which step in the inflammatory process will the patient experience first?

Vascular response

The nurse must administer hepatitis B immunoglobulin 0.5 mL intramuscularly to a 3-day-old infant born to an HB Ag-positive mother. Which injection site should the nurse choose to administer this injection?

Vastus lateralis

The patient has shiny ulcerations on a red base over the medial calf of the right leg. There is quite a bit of fluid drainage. He takes anticoagulants because of recurrent deep vein thrombosis. He also reports a sedentary lifestyle. How would the nurse classify this chronic wound?

Venous stasis ulcer

The nurse observes a new graduate nurse preparing to place an IV catheter in the patient's arm. The new graduate tells the patient, "You won't feel a thing" before inserting the needle under the skin. What ethical principle did the new graduate violate?

Veracity

The expected outcome (goal) for a patient with Disturbed Sleep Pattern is that she will:

Verbalize that she is sleeping better and feels less fatigued

The nurse is instructing a patient about performing home testing for fecal occult blood. The nurse should explain that ingestion of which substance may cause a false-negative fecal occult blood test?

Vitamin C

A patient with dementia becomes belligerent when the nurse attempts to give him a tub bath. How should the nurse proceed?

Wait for the patient to calm down, and then give him a towel bath.

The nurse is bathing a newborn infant in the nursery and notices scaly white patches over the infant's scalp. What is the most appropriate action by the nurse?

Wash the scalp and apply gentle scrubbing.

Which of the following behaviors indicates the highest potential for spreading infections among clients? The nurse:

Washes hands primarily after leaving each room

The pediatric nurse is caring for a 4-year-old child who is experiencing chronic pain secondary to tissue injury from past sickle cell anemia crises. Which of the following nonpharmacological pain reduction interventions might the nurse implement? Have the child:

Watch a funny movie

The nurse is visiting a patient who lives in a single-room occupancy hotel. The patient requires wound care and medication management. There is no running water in the room, and the bathroom down the hall is in disrepair and filthy. The patient's room is not clean. What supplies would be essential for the nurse to bring with him when visiting this client?

Waterless, antibacterial hand sanitizer solution

A patient returns from surgery with a nasogastric tube and intermittent gastric suction to provide abdominal decompression. Which of the following are correct nursing activities for managing the equipment and drainage? Select all that apply.

Wear nonsterile procedure gloves when emptying the drainage container.

The nurse is conducting a literature search. In what instance might the nurse question the reliability of the health information?

Web address ends in .net.

A patient has underlying cardiac disease and requires careful monitoring of his fluid balance. He also has a draining wound. Which of the following methods for evaluating his wound drainage would be most appropriate for assessing fluid loss?

Weigh dressings before they are applied and after they are removed.

Which is the correct formula for calculating body mass index?

Weight in kg ÷ (height in meters)2

Which assessment finding of an older adult would most concern the nurse?

Weight loss of 6% of body weight in 1 week

High-pitched breath sounds produced by airway narrowing are known as:

Wheezing

Which of the following assessment findings would help confirm a diagnosis of asthma in a client?

Wheezing on inspiration and expiration

A client approaches the nurse in the health clinic and states, "I have been dealing with my husband's illnesses for years. Now my children want me to start babysitting for my grandchildren. I don't know whether I can handle all this." What is the nurse's interpretation of this woman's statements?

When there are many stressors or when stressors continue for a long period of time, adaptation is more likely to fail.

When should the nurse assess pain?

Whenever a full set of vital signs is taken

A 38-year-old client comes into the clinic for a health examination. Knowing the psychosocial development tasks and common health problems for this age group, it would be most important for the nurse to ask:

Whether the client has episodes of feeling depressed

Which phrase is stated as a teaching goal (as compared with an objective) for a patient who had bowel resection with creation of a colostomy? The patient

Will perform ostomy self-care within 3 days after surgery

For which patient is it most important to provide frequent perineal care? The patient:

With active lower gastrointestinal bleeding

The nurse records a patient's hourly urine output from an indwelling catheter as follows: 0700: 36 mL 0800: 45 mL 0900: 85 mL 1000: 62 mL 1100: 50 mL 1200: 48 mL 1300: 94 mL 1400: 78 mL 1500: 60 mL The nurse can conclude that the patient's urine output should be described as which of the following?

Within normal limits

A 56-year-old man is hospitalized because of poorly controlled diabetes and a leg ulcer that developed as a complication of diabetes. He is awake, alert, and oriented but fatigued and in need of wound care. In the hospital, he was placed on insulin and started on a variety of oral medications. He is learning how to check his blood sugar and administer insulin. He has never given himself insulin and he does not understand how to interpret his blood sugar readings. The physician has prescribed discharge from the hospital with home health follow-up. Is this an appropriate referral?

Yes; the patient is in need of skilled services and, therefore, eligible for home care services.

Some people readily become ill when under stress. Others are able to deal with tremendous stress and remain physically and mentally healthy. This disparity is affected by a person's level of hardiness. How can you apply this knowledge to your nursing care?

You can assess for hardiness in patients; you can encourage hardy patients to learn about their illness as a means for them to be more comfortable.

For which patient is the nursing diagnosis Deficient Recall most appropriate?

Young adult admitted with acute renal failure who requires hemodialysis

The nurse assesses assigned patients and determines which patient is at highest risk for altered skin integrity?

Young adult in traction who has a low-protein diet and dehydration

Andrew is experiencing signs of appendicitis with right lower quadrant pain. He is being prepared for surgery. What type of pain is he experiencing?

acute pain

Roseanne has rheumatoid arthritis. The pain impairs her ability to be physically active. She has bad days and worse days, but the pain is always there.

chronic pain

Which is the result of the passage of stool through the colon being slowed?

constipation

Which type of seizure results from widespread electrical activity on both sides of the brain at once?

generalized seizure

Which receptor is stimulated by an unpleasant tasting medication?

gustation

Maddie, an older adult, takes a loop diuretic twice a day for congestive heart failure. She tells her daughter that she's very tired and weak, feels nauseated, and notices heart palpitations. Which electrolyte imbalance is causing the problem?

hypokalemia

The nurse is caring for an unresponsive, near-death patient in the intensive care unit and it is unclear whether or not this patient is an organ donor. The family states, "I think he put 'organ donor' on his license but we don't want to donate his organs." What is the nurse's priority action at this time?

maintain the viability of organs until a resolution is made.

A 56-year-old patient diagnosed with an acute myocardial infarction (heart attack) makes inappropriate sexual comments to the licensed practical nurse (LPN). The LPN is visibly upset. The registered nurse (RN) assigned to the patient informs the patient his behavior is unacceptable and will not be tolerated. Is the RN demonstrating holistic or mechanistic nursing?

mechanistic

Fully Compensated Metabolic Alkalosis

pH 7.40-7.45 PCO2 > 45 mm Hg HCO3 > 26 mEq/L

Uncompensated Respiratory Acidosis

pH < 7.35 HCO3 22-26 mEq/L PCO2 > 45 mm Hg

Uncompensated Metabolic Acidosis

pH < 7.35 PCO2 35-45 mm Hg HCO3 < 22 mEq/L

Partially Compensated Metabolic Acidosis

pH < 7.35 PCO2 < 35 mm Hg HCO3 < 22 mEq/L

Anne is experiencing chest pain and shortness of breath. She has tachycardia, hypertension, and tachypnea. Which nonverbal response is demonstrated?

physiological pain response

Teaching to avoid sitting with the legs crossed

promote venous return

The nurse is caring for a client who underwent extensive bowel surgery and returned to the surgical unit with a nasogastric (NG) tube in place. Which assessment finding made by the nurse indicates the client may be ready to have the NG tube removed?

return of bowel sounds