Fundementals of nursing final exam Prep Us

Which nursing assessment guideline is most accurate?

"Collect assessment data about the client continuously." Chapter 14: Assessing - Page 337

A client admitted to the hospital asks the nurse whether it would be acceptable for the client to bring food from home to eat that better meets the client's cultural preferences. What is the nurse's best response?

"Food from home is fine as long as it does not violate hospital policy or contradict the prescribed diet." Chapter 5: Cultural Diversity - Page 93

A nurse is reviewing the health history and physical assessment findings for a client who is having respiratory problems. Which client statement from the health history would be a cue to a nursing diagnosis for this problem?

"I get out of breath when I walk a few steps. The term cue is often used to denote significant data, which "raises a red flag" to look for patterns or clusters of data that signal a nursing diagnosis. In this instance, the client's statement of "getting out of breath" when walking would be a cue to assess other subjective and objective data related to the respiratory system. Chapter 15: Diagnosing - Page 366

The nurse is educating a client about restless leg syndrome. What statement made by the client indicates that further education regarding restless leg syndrome is required?

"I will try to lose weight so I can sleep better at night." Chapter 34: Rest and Sleep - Page 1211

the nurse is caring for a client who reports constipation and is presently in the bathroom attempting to have a bowel movement. The client presses the call bell and tells the nurse that about feeling dizzy. What education should the nurse provide the client about this condition?

"This occurs when bearing down and decreasing blood flow to the heart; when you stop, the blood flow will return in a larger amount." When a person bears down to defecate, the increased pressures in the abdominal and thoracic cavities result in decreased blood flow to the atria and ventricles, thus temporarily lowering cardiac output. Once bearing down ceases, the pressure is lessened, and a larger than normal amount of blood returns to the heart. This act may cause the heart rate to slow and result in syncope in some clients. Chapter 38: Bowel Elimination - Page 1420

The nurse is interviewing a client and is focusing on avoiding comments and questions that will impede communication. Which sentence demonstrates the appropriate use of communication techniques?

"When did you first notice the rash on your leg?" This is an example of a direct question that can be asked to validate information or clarify information. The other sentences demonstrate poor communication techniques. The nurse should avoid cliches, questions that require a "yes" or "no" answer, intimidating "why" and "how" questions, probing questions, and using judgmental comments. Chapter 14: Assessing - Page 335

the client is being discharged, and the nurse is reviewing the newly prescribed medications with the client. Which statement(s) will allow the nurse to evaluate the client's understanding of the medications? Select all that apply. -if you have questions, ask the pharmacist at the pharmacy where you obtain your medications." -"Tell me what time of day you are to take your medications." -"Do you have any questions about your medications?" -"What is the reason you are taking each medication?" -"I will provide you with written information about each medication before you leave."

-"Tell me what time of day you are to take your medications." -"What is the reason you are taking each medication?" Chapter 29: Medications - Page 870-871

A nurse is caring for a client with orthostatic hypotension. The client is currently not taking any antihypertensive medications. Which action(s) will the nurse take to reduce the client's risk of falls? Select all that apply. -Encourage the client to stand up from a sitting position slowly. -Educate the client about reducing salt intake in the diet. -Ensure that the client is taking an adequate volume of fluids. -Assist the client in applying compression stockings to lower extremities. -Ask the client to wait 1 hour after meals to engage in physical activity.

-Encourage the client to stand up from a sitting position slowly. -Ensure that the client is taking an adequate volume of fluids. -Assist the client in applying compression stockings to lower extremities. -Ask the client to wait 1 hour after meals to engage in physical activity. Chapter 25: Vital Signs - Page 662

A nurse is collecting a stool specimen from a client. Which measures are appropriate for this procedure? Select all that apply. -The client should be asked to void first because the lab study may be inaccurate if the stool contains urine. -The client should be asked to defecate into a clean bedpan or toilet bowl, depending on the nature of the study. -The client should be instructed not to place toilet tissue in the bedpan or specimen container. -Medical aseptic techniques are always followed. -Handwashing is performed before and after glove use when handling a stool specimen. -Generally, 2 inches of formed stool or 20 to 30 mL of liquid stool is sufficient for a stool specimen.

-The client should be asked to void first because the lab study may be inaccurate if the stool contains urine. -The client should be instructed not to place toilet tissue in the bedpan or specimen container. -Medical aseptic techniques are always followed. -Handwashing is performed before and after glove use when handling a stool specimen. Chapter 38: Bowel Elimination - Page 1428

fill in each blank in the following sentence. The nurse suggests that the clients_________ because _________

-get up 30 minutes after restlessness -it helps the mind associate the bedroom with sleeping Chapter 34: Rest and Sleep - Page 1211

Which assessment data cue does the nurse recognize as subjective data?

A pain rating of 7 Chapter 14: Assessing - Page 346

A nurse is applying the nursing process and is in the diagnosis phase. With which activities would the nurse be involved? Select all that apply. Collecting subjective and objective data Organizing data Analyzing data Identifying patterns Identifying indicators of potential dysfunction

Analyzing data Identifying patterns Identifying indicators of potential dysfunction chapter 15: Diagnosing - Page 366-367

A nurse is interviewing a client who has come to the clinic for a follow-up visit. The nurse notices the client does not make eye contact and speaks while looking down. How should the nurse respond?

Assume a position at eye level with the client and continue with the interview. Chapter 8: Communication - Page 152

Which assessment finding(s) confirms or indicates that the client is experiencing rapid-eye movement (REM) sleep? Select all that apply. Blood pressure and pulse rate show wide variations and fluctuate rapidly. The client is unable to move . Deep tendon reflexes are depressed. Muscles are relaxed, but muscle tone is maintained. The client has wet the bed.

Blood pressure and pulse rate show wide variations and fluctuate rapidly. The client is unable to move . Deep tendon reflexes are depressed. Muscles are relaxed, but muscle tone is maintained. Sleepwalking and bed-wetting are most likely to occur during non-rapid-eye movement (NREM) sleep. Chapter 34: Rest and Sleep - Page 1201-1202

A gerontologic nurse practitioner has a large client population with heart disease problems. This nurse practitioner is aware that heart disease is the leading cause of death in the aging adult. What is the cause of this trend?

Blood vessels lose their elasticity with age. Chapter 23: The Older Adult - Page 585

A client has been admitted to the medical-surgical floor for management of a fluid and electrolyte imbalance associated with decreased oral intake and excessive use of laxatives. The nurse analyzes assessment findings to identify those that may be caused by electrolyte imbalances. For each asssessment finding below, click to specify the associated electrolyte imbalance: hypokalemia, hyponatremia, or hypocalcemia. Each finding may support more than 1 disease process. confusion muscle weakness seizures tetany edema

Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1564-1566

While assessing for orthostatic hypotension, the nurse follows which step(s) when taking the blood pressure? Select all that apply Check and record blood pressure taken while the client is in the bed. If the client feels dizzy when standing, have the client sit on the side of the bed. Assist client to standing position and wait 2 to 3 minutes before taking blood pressure. Record measurements and note if the drop is ≥20 mm Hg systolic and ≥10 mm Hg diastolic. Use the same blood pressure cuff the whole time.

Check and record blood pressure taken while the client is in the bed. Assist client to standing position and wait 2 to 3 minutes before taking blood pressure. Record measurements and note if the drop is ≥20 mm Hg systolic and ≥10 mm Hg diastolic. Use the same blood pressure cuff the whole time. the client begins to feel dizzy when standing, the nurse should assist the client to a supine position to increase blood flow to the brain. Chapter 25: Vital Signs - Page 662

An older adult woman has been in the hospital for more than 1 week. While assessing her intravenous catheter port, the nurse finds a staph infection, which has developed in the past day or so. This infection is an example of which type of infection?

Healthcare-associated infection Chapter 24: Asepsis and Infection Control - Page 608

The nurse is preparing a care plan for a client recently diagnosed with obstructive sleep apnea. The client reports daytime sleepiness, fatigue, and excessive snoring that "wakes me up." What nursing diagnosis would be appropriate for this client?

Disturbed Sleep Pattern related to periods of apnea as evidenced by excessive snoring Chapter 34: Rest and Sleep - Page 1215

Which finding(s) does the nurse identify as a concern? Select all that apply. Assessment of a 70-year-old client reveals the following: Reports of napping occasionally during the day Problems with driving at night Edema of the feet with pitting Reports of dry mouth Awakening 2 to 3 times to void at night Burning on urination

Edema of the feet with pitting painful urination Chapter 23: The Older Adult.

Which quality in a nurse helps the nurse to become effective in providing for a client's needs while remaining compassionately detached?

Empathy Chapter 8: Communication - Page 165

A nurse is caring for an older adult client with arthritis. Which action is the priority for the nurse when conducting the health education for the client?

Find out what the client wants to know. Chapter 9: Teaching and Counseling - Page 194

A nurse who is preparing to administer an injection to the client states, "This injection will not be painful." The nurse has used which communication technique?

Giving false reassurance Chapter 8: Communication - Page 172

Nurses use approved NANDA-I nursing diagnoses when writing diagnoses for clients. Which diagnoses represent "Domain 1: Health Promotion" as established by NANDA-I? Select all that apply. Ineffective Health Management Risk for Disuse Syndrome Impaired Environmental Interpretation Syndrome Sedentary Lifestyle Decreased Diversional Activity Engagement Readiness for Enhanced Coping

Ineffective Health Management Sedentary Lifestyle Decreased Diversional Activity Engagement Chapter 15: Diagnosing - Page 369

An 18-year-old client is brought to the urgent care clinic reporting severe left leg pain. Which assessment(s) should the nurse prioritize for this client? Select all that apply. Pedal pulses Skin color Temperature of skin Tenderness to palpation Blood pressure

Pedal pulses Skin color Tenderness to palpation Temperature of skin Chapter 14: Assessing - Page 339

A client is being discharged to home following a diagnosis of lung carcinoma and subsequent treatment with pneumectomy surgery. The client has a prescription for continuous home oxygen. Which measure(s) will the nurse include in a teaching plan aimed at increasing oxygen-related home safety? Post a "no smoking" sign in a conspicious area. Ensure concentrators are stored flush against a wall. Keep burnable solids away from portable concentrators. Ensure tanks are stored at least 3 feet away from fire sources. Use caution with gas or electrical appliances. Avoiding storing oxygen in cooler areas of the home.

Post a "no smoking" sign in a conspicious area. Use caution with gas or electrical appliances. Oxygen concentrators should be stored away from walls to ensure adequate airflow around the device. Burnable liquids such as oils, greases, and alcohols, not solid items, away from portable concentrators. Oxygen tanks should be stored at least six, not three, feet away from sources of fire to reduce the possiblity of combustion

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action?

Remove the IV. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1578-1579

A nurse is moving to another state and will be working at an acute care facility. Prior to beginning practice, what actions should the nurse take to be compliant with state guidelines for nursing practice? Select all that apply. Research the laws and regulations that govern nursing practice in the new state Visit the state board of nursing offices Locate the state nursing practice acts Let the present state board of nursing know that the nurse is leaving the state Access educational resources related to nursing practice in another state Define the legal requirements and titles for registered nurses (RNs) and licensed practical nurses (LPNs)

Research the laws and regulations that govern nursing practice in the new state Locate the state nursing practice acts Access educational resources related to nursing practice in another state Define the legal requirements and titles for registered nurses (RNs) and licensed practical nurses (LPNs) Chapter 1: Introduction to Nursing - Page 19

The nurse is preparing to administer a bolus of furosemide 0.8 mg to a client with congestive heart failure and kidney disease. Which right of drug administration would the nurse question and confirm in this client?

Right drug In this client who has kidney disease, furosemide is contraindicated. Therefore, confirming the correct medication would be crucial. Chapter 29: Medications - Page 842

SMART goals

Specific, Measurable, Attainable, Realistic, Timely Chapter 16: Outcome Identification and Planning - Page 394

stages of sleep in relation to ease of waking as well as length of each stage

Stage I is a transitional stage between wakefulness and sleep. The client is still somewhat aware of the surroundings. Involuntary muscle jerking may occur and waken the person. This stage normally lasts only minutes. Stage II sleep is when the client is aroused with relative ease. This stage constitutes 50% to 55% of sleep. Stage III composes about 10% of sleep. This stage is when the depth of sleep increases, and arousal becomes increasingly difficult. Stage IV is when arousal from sleep is difficult. This stage is called delta sleep. This stage constitutes about 10% of sleep. The pulse, blood pressure, and respiratory rate decrease in Stage IV.

During an orientation class for new RN graduates, the nurse educator identifies which conditions as potential risks for clients to experience sleep pattern disturbance? Select all that apply. depression substance use constipation type 1 diabetes mellitus stroke glaucoma

depression substance use constipation stroke Chapter 34: Rest and Sleep - Page 1205

Which are examples of the Institute of Medicine's (IOM) recommendations for transforming the nursing profession? Select all that apply. The associate degree nurse enrolls in a program to obtain a bachelor's degree in nursing without taking any additional courses. The nurse participates in a statewide committee with other health professionals and legislators to address human trafficking. The nurse implements a research study addressing an increase in hospitalized clients with heart failure. The nurse practitioner practicing in one state is moving to another state that has a scope of practice that is more limiting. The chief nursing officer at the hospital is a non-voting board member.

The associate degree nurse enrolls in a program to obtain a bachelor's degree in nursing without taking any additional courses. The nurse participates in a statewide committee with other health professionals and legislators to address human trafficking. The nurse implements a research study addressing an increase in hospitalized clients with heart failure. Chapter 1: Introduction to Nursing - Page 20

The nurse has obtained subjective and objective assessment data for a client. Which client data require validation? Select all that apply. The client has trouble reading an informed consent document but denies needing glasses. The client has ecchymosis on the arms and legs due to a fall. The client has fever and chills related to a respiratory infection. The client is unable to eat the food being served. The client has a blood pressure reading of 124/76 mm Hg.

The client has trouble reading an informed consent document but denies needing glasses. The client has ecchymosis on the arms and legs due to a fall. When there is a discrepancy between what the person is saying and what the nurse is observing, validation is necessary to determine accuracy. Data need verification when data lack objectivity. Chapter 14: Assessing - Page 353

The nurse is caring for a client who is ordered to be in the Fowler position. When assessing the client's position in bed, the nurse will adjust the client in bed if what is observed? Select all that apply. There is a large pillow under the client's head. The client's forearms are supported on pillows. The knee gatch on the bed is engaged. The client's foot is in the plantar flexion position. There is a rolled towel beside the client's hips.

There is a large pillow under the client's head. The knee gatch on the bed is engaged. The client's foot is in the plantar flexion position. Chapter 33: Activity - Page 1159

The nurse is choosing a collection device to collect urine from a nonambulatory male client. What would be the nurse's best choice?

Urinal A bedpan is not the best choice for a male client who tend to prefer the bottle-like shape of the urinal, although female clients tend to prefer the shape of a bedpan Chapter 37: Urinary Elimination - Page 1386

The nurse is preparing to administer fluid replacement to a client. Which action should the nurse take first?

Verify the prescription for type of solution and amount of infusion. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1575

A nurse is providing an in-service program for a group of nurses who work with the older adult population. After describing the older adult population's risk for abuse and neglect, the nurse determines that the education was successful when the group identifies a vulnerable adult as having which characteristic? Select all that apply. adult 60 years or older lacking self-care ability adult with disability adult without a legal guardian adult in a long-term care facility adult receiving provider services while living in his own home

adult 60 years or older lacking self-care ability adult with disability adult in a long-term care facility adult receiving provider services while living in his own home Chapter 23: The Older Adult - Page 584

What is the term used to describe a pharmaceutical agent that relieves pain?

analgesic Chapter 35: Comfort and Pain Management - Page 1255

A client with chronic kidney disease reports not being able to urinate for the past 24 hours. A bladder scan shows no urine in the bladder. How does the nurse document this data?

anuria Chapter 37: Urinary Elimination - Page 1347

The nurse is caring for a client diagnosed with dementia. Which behaviors would the nurse most likely assess? Select all that apply. asking questions repeatedly stable mood socially inappropriate behavior wandering irritability

asking questions repeatedly socially inappropriate behavior wandering irritability Chapter 23: The Older Adult - Page 583

When reviewing data collection on a client with constipation, which factor identified by the nurse might suggest the causative factor?

client takes bisacodyl every day. Habitual use of laxatives such as bisacodyl may cause of chronic constipation Chapter 38: Bowel Elimination - Page 1435

A client's son is named to make decisions for his mother in the event she cannot speak for herself. This is an example of a(an):

durable power of attorney. Chapter 43: Loss, Grief, and Dying - Page 1691-1715

Which statement is an appropriate nursing concern for an 80-year-old client diagnosed with heart failure, with symptoms of edema, orthopnea, and confusion?

excess extracellular volume related to heart failure, manifested as edema and orthopnea Excess extracellular volume is the state in which a client experiences an excess of vascular and interstitial fluid. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1564

Nursing is described in various ways. The focus of all nursing interventions should involve which factor(s)? Select all that apply. human experience and responses of individuals, families, and groups curing the illness in individuals birth, health, illness, and death of individuals pyschosocial dimension of the client use of evidence-based practice to ensure the best care

human experience and responses of individuals, families, and groups birth, health, illness, and death of individuals pyschosocial dimension of the client use of evidence-based practice to ensure the best care Focusing on curing each illness is not possible, as some illnesses cannot be cured Chapter 1: Introduction to Nursing - Page 13

The nurse observes the client for signs of stage I pressure injury development, which most likely will include which finding?

nonblanchable redness Chapter 32: Skin Integrity and Wound Care - Page 1056

The nurse is conducting a community assessment that focuses on Healthy People 2030 health promotion guidelines. What would be important for the nurse to include when performing the community assessment to meet the Healthy People 2030 goals? Select all that apply number of health clinics violent crime rate sudden infant death syndrome (SIDS) rate number of homes with air conditioning

number of health clinics violent crime rate sudden infant death syndrome (SIDS) rate Chapter 1: Introduction to Nursing - Page 12

The primary extracellular electrolytes are:

sodium, chloride, and bicarbonate. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1558

A nurse attempts to wake a sleeping client who is scheduled for tests. The client is easily aroused from sleep. Which stage of sleep is was this client most likely experiencing?

stage 2 Stage II sleep is when the client is aroused with relative ease. This stage constitutes 50% to 55% of sleep Chapter 34: Rest and Sleep - Page 1202hapter 34: Rest and Sleep - Page 1202

The definition of Domain 1 nursing diagnoses

the awareness of well-being or normality of function and the strategies used to maintain control of and enhance that well-being or normality of function. Ineffective Health Management, Sedentary Lifestyle, and Decreased Diversional Activity Engagement are found in this category. Chapter 15: Diagnosing - Page 369