funds 1st exam

potential to produce disease depends on

-The number of organism -The virulence -The host's immune system -Length and Intimacy of contact

secondary health promotion example

Blood pressure screening, cholesterol, mammograms, colonoscopies, testicular self exams, skin

A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination? Bowel Incontinence Ulcerative Colitis Irritable Bowel Syndrome Small Bowel Obstruction

Bowel Incontinence

Examples of acute pain

Broken bones, sprains, trauma, surgery, strep throat, etc.

Which nursing qualities are helpful in winning the confidence of clients when first working with them? Select all that apply. Competence Number of years in profession Respect for client Professionalism Caring

Competence Respect for client Professionalism Caring

Which guideline should the nurse follow when including interventions in a plan of care? a. Make sure the nursing interventions are unrelated to the original outcomes. b. Date the nursing interventions when written and when the plan of care is reviewed. c. Make sure each nursing intervention does not describe the action the nurse should perform. d. Make sure the attending physician approves of and signs the nursing interventions.

Date the nursing interventions when written and when the plan of care is reviewed.

Which piece of client information is subjective? a. Alert and oriented to person and place but not time or situation b.Generalized myalgia or muscle pain c. Client has leukoplakia on her oral mucosa. d.Client is alert and oriented to person and place but not time or situation.

Generalized myalgia or muscle pain

The nurse is caring for an adolescent verbalizing a desire to seek counseling for grief related to the death of a close friend. The nurse determines that an appropriate nursing diagnosis for this client is Readiness for Enhanced Coping. What type of nursing diagnosis is Readiness for Enhanced Coping? Risk nursing diagnosis Syndrome nursing diagnosis Actual nursing diagnosis Health promotion nursing diagnosis

Health promotion nursing diagnosis

A client is being admitted from the emergency room reporting shortness of breath, wheezing, and coughing. What would the nurse formulate as an appropriate nursing diagnosis? Bronchial Pneumonia Acute Dyspnea Asthma Attack Ineffective Airway Clearance

Ineffective Airway Clearance

Which abbreviation is correct for use in documentation? BT Sub q PO Per os

PO

A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis would the nurse use to address this concern? Deficient Community Health related to chemical plant Risk for Community Contamination related to possible environmental pollution Risk for Infection related to community contamination Knowledge Deficit related to effects of chemical plant pollution

Risk for Community Contamination related to possible environmental pollution

Which information should the nurse include in a client's plan of care? Select all that apply. The client care assignment of the nursing and support staff Routine care, such as the client's bath and mouth care The minutes of the most current team conference meetings The client's problems, goals, and nursing orders The client's level of activity and current medical orders

Routine care, such as the client's bath and mouth care The client's problems, goals, and nursing orders The client's level of activity and current medical orders

Which organization audits charts regularly? Sigma Theta Tau International The Joint Commission American Nurses Association National League for Nursing

The Joint Commission

Which is the primary reason for a nurse collecting data continuously on a client? The client's health status can change quickly. It gives the nurse more information to document on the client. It makes the client feel as if the nurse is spending more time with the client. Most facilities require it for reimbursement.

The client's health status can change quickly.

reservoir

The natural habitat of an organism -People, animals, soil, food, water, objects -Carriers

An older adult client who has been living in an assisted living facility for several months informs a visiting family member that a nurse is coming to do some kind of checkup. Which type of check would be most appropriate for the nurse to perform on this client? Developmental stage assessment Focused assessment Emergency assessment Time-lapsed assessment

Time-lapsed assessment

inflammatory response; cellular

WBC (neutrophils) to the area

A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements? a client whose rehabilitation potential is not good a client whose status is stabilized a client who is homebound and needs skilled nursing care a client who is not making progress in expected outcomes of care

a client who is homebound and needs skilled nursing care

Which outcome statements are in the cognitive realm? Select all that apply. a. By 6/8/20, the client will describe a meal plan that is high in fiber. b. By 6/8/20, the client will correctly demonstrate ambulating with a walker. c. Within 1 week after teaching, the client will list three benefits of quitting smoking. d. By 6/8/20, the client will correctly demonstrate self-injecting insulin. e. Before discharge, the client will verbalize valuing health sufficiently to follow a healthy diet. f. After viewing the film, the client will verbalize four benefits of daily exercise.

a. By 6/8/20, the client will describe a meal plan that is high in fiber. c. Within 1 week after teaching, the client will list three benefits of quitting smoking. f. After viewing the film, the client will verbalize four benefits of daily exercise.

Which of the following are examples of chronic illness? a.Diabetes mellitus b.COPD c.Bronchial pneumonia d.Rheumatoid arthritis e.Cystic fibrosis f.Fractured hip Otitis media

a.Diabetes mellitus b.COPD d.Rheumatoid arthritis e.Cystic fibrosis

A nurse obtaining the most important information first during an assessment of a client is primarily an example of the nurse being: able to prioritize. factual. purposeful. complete.

able to prioritize

psychomotor interventions include

activities such as positioning, inserting, and applying

The nurse recognizes that health problems that the nurse can address by independent nursing interventions are called: collaborative nursing diagnoses. actual or potential nursing diagnoses. dependent nursing diagnoses. syndrome nursing diagnoses.

actual or potential nursing diagnoses.

While standing on the right side of the client, the nurse observes that the client does not respond when spoken to. After assessing the client the nurse charts, "The client's hearing may be impaired on the right side." This statement is an example of: an inference. erroneous data. a cue. duplicate data.

an inference

types of infectious agents

bacteria, viruses, fungi, parasites

Low income individuals and people of color face increased

barriers to accessing care, receive poorer quality of care, and ultimately experience worse health outcomes.

tertiary health promotion

begins after an illness is diagnosed with the goal of reducing disability and helping rehabilitate patients to maximum level of functioning.

Which group of terms best defines assessing in the nursing process? a. Designing a plan of care, implementing nursing interventions b. Nurse-focused, establishing nursing goals c. Collection, validation, communication of client data d. Problem-focused, time-lapsed, emergency-based

c. Collection, validation, communication of client data

Which is the primary benefit of outcome identification? a. It allows for the identification of proper diagnoses. b. It allows the nurse to evaluate the outcomes. c. It promotes the client being an active participant in care. d. It promotes an effective diagnostic process.

c. It promotes the client being an active participant in care.

Which is an example of a nurse-initiated intervention? a. Administer morphine sulfate 2 mg intravenous push every 3 hours as needed for pain. b. Administer a 1000-mL soap suds enema. c. Teach the client how to splint an abdominal incision when coughing and deep breathing. d. Administer oxygen at 4 L/min per nasal cannula.

c. Teach the client how to splint an abdominal incision when coughing and deep breathing.

The nurse is about to record the fluid intake for a client with congestive heart failure. Which documentation is most appropriate? a.The client consumed an adequate fluid intake for the 8-hour shift. b.The client consumed a normal amount of fluid for the 8-hour shift. c.The client consumed 780 mL of fluid for the 8-hour shift.

c.The client consumed 780 mL of fluid for the 8-hour shift.

Which is the best source of information for the nurse when collecting data for an assessment? a.Primary physician b.Charge nurse c.Client d.Medical record

client

Which type of health problem requires both physician- and nurse-prescribed actions to address?

collaborative health problem

Which is an example of a nursing diagnosis? Hypoglycemia Depression Dehydration Constipation

constipation

disparities limit

continued improvement in overall quality of care and population health and result in unnecessary costs. It is estimated that the our economy loses an estimated $309 billion per year due to the direct and indirect costs of disparity.

With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include? Select all that apply. current orders what time the nurse will return for the next shift any abnormal occurrences with the client during the shift identifying demographics, including diagnosis

current orders any abnormal occurrences with the client during the shift identifying demographics, including diagnosis

health care disparities refers to

differences in health and healthcare between populations. It refers to a higher burden of illness, injury, disability, or mortality experienced by 1 group relative to another. It includes race, ethnicity, socioeconomic status, age, location, disability status and sexual orientation.

prodromal

early signs of illness -nonspecific symptoms -most contagious stage

comprehensive assessment

encompasses all of the assessment data for the client.

Heart disease and stroke are the

first and third leading causes of death, accounting for more than 30% of all U.S. deaths each year.

functional assessment

focuses on areas that relate to the physical performance of activities, such as how the client is able to meet activities of daily living, demonstration of cognitive abilities, and social functioning

What must the nurse do to identify actual or potential health problems? Meet with significant others Evaluate care implemented Call the physician Gather data from sources

gather data from sources

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients: need to obtain legal representation to update their health records. have the right to copy their health records. are required to obtain health record information through their insurance company. can be punished for violating guidelines.

have the right to copy their health records

A nurse documents the following nursing diagnosis on a client's plan of care: "Readiness for Enhanced Breast-Feeding." The nurse has identified which type of nursing diagnosis? Health promotion Risk Syndrome Problem-focused

health promotion

The nurse caring for an older adult client suspects that the client is being neglected at home due to several observations obtained in the ongoing assessment. What is the appropriate nursing action in this situation? discuss the abuse with coworkers to determine what should be done immediately report the suspected abuse of the client. inform the client's family that the client is being neglected at home avoid reporting the abuse as it would be a privacy and confidentiality violation

immediately report the suspected abuse of the client.

inflammatory response; vascular stage

increased blood flow to area

stages of infection

incubation, prodromal, full stage of illness, convalescent

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: important information. factual statement. interpretation of data. relevant data.

interpretation of data.

incubation

interval between exposure and appearance of symptoms

database assessment

is performed during the initial history and physical portion of the client's illness and represents a comprehensive and all inclusive initial collection of data.

diabetes is the

leading cause of kidney failure, non-traumatic lower extremity amputations, and new cases of blindness each year among U.S. adults aged 20-74 years.

•Health risk factors can be defined as

modifiable or non-modifiable

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation? Documenting clients' health histories and discharge planning Omitting clients' responses to nursing interventions Identifying nursing diagnoses or clients' needs Recording nursing interventions

omitting client's responses to nursing interventions

The nurse is conducting a client interview and notices that the client answers every question with a "yes" or "no" response. Which is most likely the cause of this action by the client? Low anxiety Sleepiness Hunger Pain

pain

primary health promotion

promoting health and preventing the development of disease (teaching)

When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent?

psychomotor

convalescent

recovery period

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease and their families. Providing this information is an example of: conferring. reporting. a referral. a consultation.

referral

cancer is the

second leading cause of death, claims more than half a million lives each year.

A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care? a. Follow institutional guidelines. b. Seek research about the disorder. c. Set priorities using client care standards. d. Consult with another nurse.

seek research about the disorder

A client describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue is a client's description of pain in the right leg?

subjective

arthritis is

the most common cause of disability, limits activity for 19 million U.S. adults.

portal of exit

the point of escape -Most organisms have a primary exit route -Human routes include respiratory, GI, GU, breaks in skin, blood vessels, tissue

primary health promotion examples

◦Immunizations, teaching healthy diet, exercise, smoking cessation, accident prevention, safety

most common chronic diseases

◦heart disease, stroke ◦ cancer ◦ diabetes ◦ arthritis

A client is scheduled for a CABG procedure. What information should the nurse provide to the client? "A complete ablation of the biliary growth will decrease liver inflammation." "The CABG procedure will help increase intestinal motility and prevent constipation." "The CABG procedure will help identify nutritional needs." "A coronary artery bypass graft will benefit your heart."

"A coronary artery bypass graft will benefit your heart."

A staff nurse comments to the charge nurse that it is unnecessary to know how to formulate nursing diagnoses because the computerized documentation system generates them automatically. What is the most appropriate response by the charge nurse? "A nurse is still responsible for using critical thinking to determine the validity of the nursing diagnoses generated." "Using computerized documentation systems allows for the standardization of client care." "Computerized documentation systems have eliminated the need for nurses to worry about nursing diagnoses." "The use of nursing diagnoses generated by a computerized documentation system is not responsible nursing practice."

"A nurse is still responsible for using critical thinking to determine the validity of the nursing diagnoses generated."

A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate? "Clipboards with client data should not leave the unit." "You can get an electronic printout of client lab data to take with you." "Be sure to write down specific information for your clinical paperwork." "Be sure to put the client's name and room number on all paperwork."

"Clipboards with client data should not leave the unit."

When recording or documenting outcome attainment in the chart, nurses are to be very clear with the descriptions used. Which term is appropriate? "Great response" "Inadequate skills" "Extremely well-mannered" "Demonstrated steps"

"Demonstrated steps"

The unit nurse manager has just completed a workshop on best practices on documentation. Which statements made by the nurse would indicate that learning was effective? Select all that apply. "I will draw a straight line through any blank space." "I will elaborate on the details on my entry in the clients' records." "I will use only agency-approved abbreviations." "I will write, print, or type information legibly." "I will stay logged in on the computer until the end of my shift."

"I will draw a straight line through any blank space." "I will use only agency-approved abbreviations." "I will write, print, or type information legibly."

A nurse is requesting to receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is most appropriate? "It will let me see everything that has been done and things that need to be done." "It makes our client feel like we care, especially if we start the day off with a clean room." "It will allow for us to see the client and possibly increase client participation in care." "It will give me a better sense of what my workload will be today."

"It will allow for us to see the client and possibly increase client participation in care."

The unlicensed assistive personnel (UAP) has taken vital signs on a newly admitted client. The client asks the nurse how this information is recorded in the chart, since the UAP is not licensed. Which response by the nurse is best? "Vital signs do not need to be recorded unless they are abnormal." "The UAP logs in under my name and documents the vital signs." "The UAP will tell me what the vital signs are, and I will record them in the record so the health care provider can review them." "The UAP is able to log in and enter the information so all members of the health care team can see it."

"The UAP is able to log in and enter the information so all members of the health care team can see it."

Immune Response-

-Humoral Immunity- antigen-antibody reaction -Cellular Immunity- increased WBC (lymphocytes)

Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? A client wishes to appeal her insurance company's refusal to reimburse for a diagnostic test. A client has asked a nurse if he can read the documentation that his physician wrote in his chart. A client has asked for a second opinion regarding treatment options for her diagnosis of ovarian cancer. A client who resides in Indiana has required hospitalization during a vacation in Hawaii.

A client has asked a nurse if he can read the documentation that his physician wrote in his chart.

The nurse is providing safety teaching to the family of an older adult client. Which finding in the client's home will the nurse teach the family to address? No extension cords are being used. Outlets and switches have cover plates. A hair dryer is placed next to the sink. Machines used infrequently are unplugged.

A hair dryer is placed next to the sink.

Which statement is true regarding addressing a priority problem? Priority problems are identified at predetermined intervals throughout the shift. Addressing priority problems involves skipping interventions. A priority problem requires a nursing intervention before another problem is addressed. The priority of problems is established and continued according to the nursing plan of care.

A priority problem requires a nursing intervention before another problem is addressed.

The nurse is preparing to interview a client who demonstrates significant abdominal pain and rates the pain at 10 on a 0 to 10 pain scale. What action by the nurse can improve the outcome of the interview?

Administer prescribed pain medication prior to conducting the interview

The nurse is using the ISBARR format to report a surgical client's deteriorating condition to a health care provider. Which actions would the nurse perform when using this guide? Select all that apply. After introductions, the nurse states the client name, room number, and problem. The nurse reads back the physician's new orders at the conclusion of the call. The nurse asks the health care provider to comment on the present situation before giving recommendations. The nurse asks the health care provider to describe the admitting diagnosis of the client. The nurse asks the health care provider to estimate the discharge date for the client. The nurse states that the client's condition "could be life-threatening."

After introductions, the nurse states the client name, room number, and problem. The nurse reads back the physician's new orders at the conclusion of the call. The nurse states that the client's condition "could be life-threatening."

A nurse suspects that the client with Crohn's disease does not understand the medication regimen or diet modifications required to manage the illness. What is the nurse's most appropriate action? Refer the client to available community resources and support groups. Ask the client to verbalize the medication regimen and diet modifications required. Ask the gastroenterologist to explain the treatment plan to the client and family again. Ask the nutritionist to give the client strict meal plans to follow.

Ask the client to verbalize the medication regimen and diet modifications required.

The nurse has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention? Discuss the client's feelings about the illness. Assess the client's response to the ambulation. Document the client's ambulation. Inform the client when ambulation is scheduled next.

Assess the client's response to the ambulation.

The nurse is caring for an older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first? Assess the need for assistance with ambulation. Put the client's bedside rails up. Arrange furniture so that the client has something to hold on to. Apply socks to the client's feet.

Assess the need for assistance with ambulation.

Which nursing action can be categorized as a surveillance or monitoring intervention? Use of therapeutic communication skills Administering a paracetamol tablet Auscultating of bilateral lung sounds Providing hygiene

Auscultating of bilateral lung sounds

A nurse is educating parents of preschoolers on appropriate safety measures for this age group. What might be a focus of the education plan? Childproofing the house Safety equipment for playing sports Smoking cessation Back to sleep guidelines

Childproofing the house

A client with a right facial droop and dysphagia after a stroke has the nursing diagnosis "Impaired Swallowing." Which expected client outcome is most effective? Client will chew food well and use a tongue sweep. Client will avoid straws and drink thickened liquids. Client will sit in chair for all meals and snacks. Client will use chin tuck and double swallow for each bite.

Client will use chin tuck and double swallow for each bite.

A client in the last stages of pancreatic cancer tells the nurse, "I am tired of fighting. I am ready to die." What is the nurse's best action? Remind the client that positive thoughts are essential for recovery. Research other treatment options available for the client. Ask if the client would like to speak with a spiritual adviser. Collaborate with other disciplines to plan end-of-life care for the client.

Collaborate with other disciplines to plan end-of-life care for the client.

Which statement related to the evaluation of outcome attainment for a client is correct? Collecting data related to outcome attainment requires the nurse to know when to collect the data, based upon established time criteria. The nurse should initially evaluate the plan of care at the time of the client's discharge. Evaluation of the client's attainment of outcome goals is determined by the nurse and physician. Celebrating outcome achievement with a client often interferes with attainment of future goals. SUBMIT ANSWER

Collecting data related to outcome attainment requires the nurse to know when to collect the data, based upon established time criteria.

After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action? Reassess the client for improvement in 30 minutes. Document the interventions and the result. Determine the client's code status in case of an emergency. Communicate with the physician for additional orders.

Communicate with the physician for additional orders.

Which parts of the nurse's decision about care occur after evaluating the client's responses to the plan of care? Select all that apply.' Continue the plan of care Begin the plan of care Communicate the plan of care Terminate the plan of care Modify the plan of care

Continue the plan of care Terminate the plan of care Modify the plan of care

The nurse on a busy acute care floor identifies that several clients with heart failure are being readmitted within 2 weeks of discharge. Which step in performance improvement is the nurse demonstrating? Discovering a problem Planning a strategy using indicators Assessing the change Implementing a change

Discovering a problem

Which action should the nurse take during the evaluation phase of the nursing process? Have the client give input into plan of care upon admission. Document reassessment of pain after medication administration. Provide the client with a follow-up appointment after discharge. Discontinue the indwelling urinary catheter per the provider's order.

Document reassessment of pain after medication administration.

A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order? Ensure that two fingers can be inserted between the restraint and the client's extremity. Remove the restraint at least every 4 hours, or according to facility policy. Use a quick-release knot to tie the restraint to the side rail. Apply restraints to the hands or wrists, never to the ankles.

Ensure that two fingers can be inserted between the restraint and the client's extremity.

The nurse is caring for a postoperative client who reports ineffective pain management with pain rated a 7 on a 0-10 rating scale. Based on the information provided by the client, which step should the nurse take first to modify the care plan? Evaluate the use of current pain relief measures. Request a stronger analgesic from the provider. Provide additional relief with non-pharmacologic measures. Create a new nursing diagnosis to reflect new goals.

Evaluate the use of current pain relief measures.

A nurse documents the following nursing diagnosis on a client's plan of care: "Fluid Volume Deficit related to gastrointestinal upset from food poisoning as evidenced by vomiting and diarrhea for the past three days, slow skin turgor, and weight loss." The nurse identifies which part of the statement as the etiology? Slow skin turgor Fluid volume deficit Gastrointestinal upset from food poisoning Vomiting

Gastrointestinal upset from food poisoning

A client recently diagnosed with pancreatic cancer tells the nurse, "I don't see any hope for my future." What would be the most appropriate nursing diagnosis for the nurse to formulate to address this health problem? Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis Ineffective Health Maintenance related to being overwhelmed by cancer diagnosis Disturbed Self-Concept related to pancreatic cancer diagnosis Knowledge Deficit: Cancer treatment options related to new diagnosis

Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis

Which statement should the nurse include in the education plan regarding safety issues for a group of adult clients? Suicide is the leading cause of death in adults and adolescents. Occupational safety practices can eliminate all workplace hazards. In most age groups, motor vehicle accidents are major causes of death. Environmental lead exposure is a primary cause of death in adult clients.

In most age groups, motor vehicle accidents are major causes of death.

The nurse is preparing a client with a bowel obstruction for emergency surgery. Which intervention has the highest priority for this client? Instruct the client and family in wound care. Discuss discharge plans with the client. Teach the client about dietary restrictions during recovery. Inform the client what to expect after the surgery.

Inform the client what to expect after the surgery.

A resident of a nursing home keeps trying to get out of bed to use the bathroom, despite having a urinary catheter in place. Which intervention will best preserve this client's safety and could be used as an alternative to restraints? Limit the resident's fluid intake in order to reduce his or her urge to void. Increase the resident's physical activity to reduce evening restlessness. Investigate the possibility of discontinuing his or her catheter. Collaborate with the resident's health care provider to have his or her diuretics discontinued

Investigate the possibility of discontinuing his or her catheter.

A nurse has been exposed to feces while changing the linens of a client's bed. Which guideline is followed for performing handwashing after this client encounter? Remove all jewelry, including wedding bands, before hand washing. Pat dry with a paper towel, beginning with the forearms and moving down to fingertips. Keep hands lower than elbows to allow water to flow toward fingertips. Use an alcohol-based hand rub to decontaminate the hands.

Keep hands lower than elbows to allow water to flow toward fingertips.

The physician has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action? Medicate the client and wait to ambulate later. Ambulate the client and medicate later. Explain to the client the benefits of ambulation. Emphasize to the client the importance of following the treatment plan.

Medicate the client and wait to ambulate later.

Which nursing action would be most effective in helping a client learn self-care behaviors? Check with the client to ensure that personal self-care goals are being met. Collect data on the number of self-care activities the client has performed that day. Model self-care behaviors for the client. Ask client to discuss the client's goals for the day at the start of the shift.

Model self-care behaviors for the client.

A school nurse is providing information to a group of older adults during Fire Prevention Week. Which statement is correct regarding fires in the home? Most home fires are caused by children playing with matches. Most fatal home fires occur while people are cooking. Most people who die in house fires die of smoke inhalation rather than burns. About 10% of home fire deaths occur in a home without a smoke detector.

Most people who die in house fires die of smoke inhalation rather than burns.

The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action? Notify the physician for additional orders. Document the client's level of consciousness. Decrease stimulation and allow the client to rest. Consult with another nurse to validate the assessment.

Notify the physician for additional orders.

What is the rationale for health care personnel to orient clients to rooms and equipment when they are admitted to the hospital? Orienting clients to the surroundings decreases the potential for injury. It is part of the routine and is included on the admission checklist. It is hospital policy. It allows time for the health care provider to write admission orders.

Orienting clients to the surroundings decreases the potential for injury.

The emergency room nurse is performing an initial assessment of a new client who presents with severe dizziness. The client reports a medical history of hypertension, gout, and migraine headaches. Which step should the nurse take first in the comprehensive assessment? Initiate an intravenous line and administer 500mL of normal saline. Perform a full review of systems. Discuss the need to change positions slowly, especially when moving from sitting to standing. Perform vital signs and blood glucose level.

Perform vital signs and blood glucose level.

The nurse is caring for a client who has active tuberculosis and is under airborne precautions. The health care provider prescribes a computed tomography (CT) examination of the chest. Which action by the nurse is appropriate? Place a surgical mask on the client and transport to the CT department at the specified time. Question the need for the examination, because the client must remain under airborne precautions. Notify the CT department in advance so other clients and staff can be removed from the area. Request that the examination be done at the bedside.

Place a surgical mask on the client and transport to the CT department at the specified time.

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? Retrieve a unit of blood from the blood bank. Provide the client with assistance in transferring to the bedside commode. Assess an IV site for possible infiltration Reassess the client's sacrum for redness when doing a bed bath.

Provide the client with assistance in transferring to the bedside commode.

A nurse is caring for a client after a repair of a left femur fracture. The client is immobilized and on strict bed rest, and the nurse provides assistance with position change every 2 hours to prevent pressure injuries. What is the "to prevent pressure injuries" portion of this statement described as? Rationale Nursing intervention Outcome Nursing diagnosis

Rationale

The nurse has instructed the client in self-catheterization, but the client is unable to perform a return demonstration. What is the nurse's most appropriate plan of action? Revise the plan to include the inclusion of a support group. Teach the content again utilizing the same method. Report the client's inability to learn to the case manager. Reassess the appropriateness of the method of instruction.

Reassess the appropriateness of the method of instruction.

Before implementing any planned intervention, which action should the nurse take first? Reassess the client to determine whether the action is needed. Record the planned intervention in the client's medical record. Ask the client whether this is a good time to do the intervention. Have the required equipment ready for use.

Reassess the client to determine whether the action is needed.

After completing a client abdominal assessment, the nurse finds diminished bowel sounds. To determine what intervention is needed, which step would the nurse take first? Prepare the client for administration of laxative medication. Review the client's recent food and fluid intake. Encourage the client to drink more fluids and eat more fiber. Provide teaching about the prevention of constipation.

Review the client's recent food and fluid intake.

Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action? Continue assisting the client to the bathroom to ensure the client's safety. Consult with the physical therapist to determine the client's ability. Revise the care plan to allow the client to ambulate to the bathroom independently. Instruct the client's family to assist the client to ambulate to the bathroom.

Revise the care plan to allow the client to ambulate to the bathroom independently.

Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action? Instruct the client's family to assist the client to ambulate to the bathroom. Continue assisting the client to the bathroom to ensure the client's safety. Consult with the physical therapist to determine the client's ability. Revise the care plan to allow the client to ambulate to the bathroom independently.

Revise the care plan to allow the client to ambulate to the bathroom independently.

The nurse is caring for a client who has an elevated temperature. When calling the health care provider, the nurse should use which communication tools to ensure that communication is clear and concise? PIE SBAR MAR SOAP

SBAR

The nurse admitting a client with a new diagnosis of diverticulitis plans to teach the client about managing the disorder after discharge. What nursing intervention most completely meets the client's needs? a. Ask the client's learning style, then teach diet information using that style. b. Answer the client's questions about diet alterations, and then evaluate understanding. c. Start from client's knowledge, teach about diet modifications, and check for learning. d. Present the client with videos and books about diet changes that reduce inflammation.

Start from client's knowledge, teach about diet modifications, and check for learning.

A nurse is working with a client who is having a difficult time accepting a new diagnosis of type 2 diabetes. The nurse pulls up a chair next to the client's bed and holds the client's hand while listening to the client's story. What type of nursing intervention is the nurse engaging in? Supportive Supervisory Psychosocial Coordinating

Supportive

The nurse has assessed a client and determined that the client has abnormal breath sounds and low oxygen saturation level. The nurse is performing what type of nursing intervention? Surveillance Collaborative Maintenance Supportive

Surveillance

The nurse is caring for a 10-year-old client who is newly diagnosed with a seizure disorder. What variable would alter the nurse's plan for educating the client and parent? The parents verbalize acceptance of the need to closely monitor their child's condition. The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years. The client expresses a desire to learn how to manage the medication regime. The parents have comprehensive insurance coverage for their family's medical care.

The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years.

A client has been recently diagnosed with diabetes after receiving emergency treatment for a hyperglycemic episode. Which of the client's actions indicates that the client has achieved a cognitive outcome in the management of this new health problem? The client can demonstrate the correct technique for using a new glucometer. The client expresses a desire to change the way that the client eats and exercises. The client is able to explain when and why the client needs to check the blood glucose level. The client has maintained blood glucose levels within acceptable range in the days prior to discharge.

The client is able to explain when and why the client needs to check the blood glucose level.

The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the education plan? Select all that apply. The client is blind. The client denies the need for education. The client is an architect. The client is married. The client is male.

The client is blind. The client denies the need for education.

Which are cognitive client outcomes? Select all that apply. The client lists the side effects of digoxin. The client identifies signs and symptoms of hypoglycemia. The client describes how to perform progressive muscle relaxation. The client reports cycling 30 minutes three times each week. The client correctly ambulates with a walker.

The client lists the side effects of digoxin. The client identifies signs and symptoms of hypoglycemia. The client describes how to perform progressive muscle relaxation.

The following statement is documented in a client's health record: "Patient c/o severe H/A upon arising this morning." Which interpretation of this statement is most accurate? The client is coughing and experiencing severe heartburn in the morning. The client reports waking up this morning with a severe headache. The client has a history of severe complaints in the morning. The client has symptoms in the morning associated with a heart attack.

The client reports waking up this morning with a severe headache.

A client diagnosed with advanced lung cancer has a nursing diagnosis of Ineffective Coping. What assessment data would provide evidence to the nurse for this diagnosis? The client asks about hospice services. The client states, "I am sure the doctors have misdiagnosed me." The client states, "I hope that I am able to attend my daughter's wedding." The client makes funeral plans.

The client states, "I am sure the doctors have misdiagnosed me."

Which outcome for a client with a new colostomy is written correctly? The client will be able to care for stoma and cope with psychological loss by 3/29/20. The client will know how to care for the stoma by 3/29/20. Explain to the client the proper care of the stoma by 3/29/20. The client will demonstrate proper care of the stoma by 3/29/20.

The client will demonstrate proper care of the stoma by 3/29/20.

The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel? The client who needs vital signs taken following infusion of packed red blood cells. The client who requires assistance dressing in preparation for discharge. The client with continuous pulse oximetry who requires pharyngeal suctioning. The client who is pleasantly confused and requires assistance to the bathroom.

The client with continuous pulse oximetry who requires pharyngeal suctioning.

Which nurse is using criteria to determine expected standards of performance? The nurse preceptor provides feedback to the new graduate nurse after 6 weeks of orientation. The new graduate nurse consults the policies and procedures of the institution prior to skill implementation. The nurse seeks information from the unlicensed assistive personnel (UAP) regarding the family's response to the nurse's education. The nurse manager provides the staff nurse feedback regarding job performance for the previous year.

The new graduate nurse consults the policies and procedures of the institution prior to skill implementation.

Which of the following best summarizes the evaluation step of the nursing process? The client and family have met health care goals and no longer need care. The nurse and client measure achievement of planned outcomes of care. The nurse completes a health assessment to establish a database. The nurse and client identify nursing diagnoses and appropriate interventions.

The nurse and client measure achievement of planned outcomes of care.

Which nursing action reflects evaluation? The nurse sets an anxiety level of 3 or less with the client. The nurse identifies that the client has wound drainage. The nurse performs colostomy irrigation. The nurse assesses the client's response to pain medication.

The nurse assesses the client's response to pain medication.

Which nursing action reflects evaluation? The nurse identifies that the client does not tolerate activity. The nurse assesses urine output following administration of a diuretic. The nurse sets a tolerable pain rating with the client. The nurse auscultates the client's lungs and abdomen.

The nurse assesses urine output following administration of a diuretic.

Which finding from a nursing audit reflects high standards for client safety and institutional health care? The nurse fails to adequately complete data on clients' health histories and discharge planning. The nurse records inappropriate nursing interventions. The nurse fails to identify the nursing diagnoses or clients' needs. The nurse documents clients' responses to nursing interventions.

The nurse documents clients' responses to nursing interventions.

A nurse evaluates clients prior to discharge from a hospital setting. Which action is the most important act of evaluation performed by the nurse? The nurse evaluates the plan of care. The nurse evaluates the types of health care services available to the client. The nurse evaluates the client's goal/outcome achievement. The nurse evaluates the competence of nurse practitioners.

The nurse evaluates the client's goal/outcome achievement.

The nurse has identified the following outcome for the client: The client will have a soft, formed stool. Which error has the nurse made in writing the outcome? The nurse has omitted the defining characteristics. The outcome should indicate what the nurse will do. The nurse has not made any error in writing the outcome. The nurse has omitted the time frame.

The nurse has omitted the time frame.

A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct regarding the filing of a safety event report? The nurse should make a copy of the safety event report and place it in the client's medical record. The nurse should include a note on the client's chart that mentions the report. The nurse should await results of the x-ray before filing the report. The nurse should record the incident in the client's medical record and fill out a safety event report separately.

The nurse should record the incident in the client's medical record and fill out a safety event report separately.

Why are quality-assurance programs important in nursing? They specify how resources are used or not used. They facilitate increased enrollment in educational programs. They enable nursing to be accountable for the quality of care. They allow increased retention of qualified nurses.

They enable nursing to be accountable for the quality of care.

A nurse is preparing to implement an order for the use of restraints to ensure a client's safety. Which statement accurately describes a guideline to follow? Individualize the use of restraints and choose the most easily used device. Respond to the past history of the client (including previous falls) to determine the need for restraints. Alert the health care provider and the client's family if restraints are ordered by the client's primary nurse. Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others.

Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others.

Assessment of a client with difficulty breathing reveals that the client has thick, tenacious secretions in the trachea and bronchi and excessive sputum with coughing. The respiratory rate is slightly increased. When developing this client's plan of care, which intervention would the nurse include? Limit fluids to 1,000 ml per day Mechanical ventilation Tracheobronchial suctioning Assisted ambulation

Tracheobronchial suctioning

The nurse admitting a client with a new diagnosis of diverticulitis plans to teach the client about managing the disorder after discharge. What nursing intervention most completely meets the client's needs? a. Start from client's knowledge, teach about diet modifications, and check for learning. b. Answer the client's questions about diet alterations, and then evaluate understanding. c. Ask the client's learning style, then teach diet information using that style. d. Present the client with videos and books about diet changes that reduce inflammation.

a. Start from client's knowledge, teach about diet modifications, and check for learning.

A client had a cholecystectomy 2 hours previously and is waking up from anesthesia. The client asks, "how long it will be before I can go home?" The nurse responds that most clients are discharged within 2 days. The nurse's answer is most likely based on which piece of information? a. The agency's critical path b. The client outcomes c. The individualized plan of care d. The scientific rationale

a. The agency's critical path

"The levels of performance accepted by and expected of nursing staff or other health team members" defines: a. standards. b. evidence-based practice. c. evaluation. d. criteria.

a. standards.

The nurse caring for clients at an outpatient clinic determines that which client is at greatest risk for infection? a 2-year-old toddler an 80-year-old woman a 12-year-old girl an 18-month-old infant

an 80-year-old woman

For which client would the use of standard precautions alone be appropriate? a. a client with diphtheria who needs p.m. care b. an incontinent client in a nursing home who has diarrhea c. a child with chickenpox who is treated in the emergency room d. a client with TB who needs medications administered

an incontinent client in a nursing home who has diarrhea

Which term describes foreign particles that enter a host and stimulate the body's immune response?

antigen

A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using? a. Guidelines b. A standardized care plan c. An order set d. An algorithm

b. A standardized care plan

Discharge plans for a client with a mental health disorder include living with family members. The nurse learns that the family is no longer willing to allow the client to live with them. What is the nurse's most appropriate action? a. Inform the family that it is not possible to change the discharge plans. b. Collaborate with other disciplines to revise the discharge plans. c. Instruct the client to make alternate living arrangements. d. Communicate with the physician about additional orders.

b. Collaborate with other disciplines to revise the discharge plans.

A nurse is caring for a client who was admitted 2 days ago following surgery. The client has diminished lung sounds in the posterior bases. What is the best action by the nurse? a. Provide oral pain medication before ambulation. b. Encourage hourly use of the incentive spirometer. c. Reassess in 4 hours and document the findings. d. Promote oral fluid intake between meals.

b. Encourage hourly use of the incentive spirometer.

The nurse ascertains that a client is failing to follow the plan of care that was collaboratively developed. Further investigation determines that the plan of care is not appropriate for this client. What is the nurse's next step in correcting this problem? a. Provide information to the client on the benefits of complying with the plan of care. b. Ask the client's family to assist the client in following the plan of care. c. Make changes in the plan of care based upon assessment data. d. Discuss the desired outcomes with the client and the importance of the outcomes.

c. Make changes in the plan of care based upon assessment data.

The client identifies three strategies for minimizing leakage of an ileostomy bag. This is an example of: a. an affective outcome. b. a physiologic outcome. c. a cognitive outcome. d. a psychomotor outcome.

c. a cognitive outcome.

The primary purpose of nursing implementation is to: a. implement the critical pathway for the client. b. improve the client's postoperative status. c. help the client achieve optimal levels of health. d. identify a need for collaborative consults.

c. help the client achieve optimal levels of health.

Identifying the kind and amount of nursing services required is a possible solution for: a. nurses who are bored. b. nurses frustrated with substandard care. c. inadequate staffing. d. clients who fail to communicate their needs.

c. inadequate staffing.

The nurse is caring for a pediatric client with whooping cough. Which precautions will the nurse begin? contact droplet airborne

droplet

Priority setting is based on the information obtained during reassessment and is used to rank nursing diagnoses. Each factor contributes to priority setting except which? Feedback from the family Time and resources The client's condition Finances of the client

finances of the client

A client with a history of benign prostatic hyperplasia presents to the emergency room with reports of urinary retention. The nurse collects data related to the client's voiding patterns, weight gain, fluid intake, urine volume in the bladder, and level of suprapubic discomfort. What type of assessment is the nurse performing? Time-lapse Initial Focused Emergency

focused

psychosocial intervention include

focuses on supporting, exploring, and encouraging

The home health nurse is performing an assessment related to the client's ability to manage activities of daily living in the home environment. Which assessment is the nurse performing?

functional assessment

The residential home nurse is caring for a client who lives in an assisted living unit. In designing a plan of care to prevent fires, the nurse identifies which as the highest risk to the client? cigarette smoking gas stove electrical sockets clothes dryer

gas stove

The nurse is getting ready to change the client's wound dressing. Which step best supports infection control? handwashing sterile gloves sterile guaze

handwashing

A nurse is taking stock of the equipment in the room of an older adult client with pneumonia who has been on parenteral nutrition for a long time. Which equipment can transmit infection to older adult clients?

indwelling catheter

A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing:

intervention

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: ensuring that abbreviations are understandable to clients who may seek access to their health records. using only abbreviations whose meaning is self-evident to an educated health professional. using only those abbreviations that are defined in full at another location in the client's chart. limiting abbreviations to those approved for use by the institution.

limiting abbreviations to those approved for use by the institution.

The nurse is assigned a client who had an uneventful colon resection 2 days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change? A senior nursing student present for clinical Licensed practical nurse Nursing assistant Registered nurse

nursing assistant

The nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining? Cost-effectiveness Structure Outcome Process

outcome

A mother brings an infant into the clinic. The infant is 2 months old and has not been gaining weight appropriately. The outcome statement on the plan of care states, "The infant will double birth weight by 6 months of age." This is an example of which type of outcome statement? Affective Physical changes Cognitive Psychomotor

physical changes

A client is experiencing generalized weakness and body aches. In the progress of infection, the client is in the: prodromal period incubation period acute period convalescent period

prodromal period; characterized by nonspecific symptoms such as nausea, fever, general weakness, or aches and pains.

Which action by the unlicensed assistive personnel (UAP) requires intervention from the nurse when providing care to an older adult client who is at risk for falls? has client sit in bed for a few moments before standing provides slippers for ambulation places bed at lowest setting clears a path from bed to bathroom

provides slippers for ambulation; better footwear should be given

focused assessment

relies on one area of functioning such as the respiratory system if a client is having an asthma attack

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action?

reporting

The most common infection in children is:

respiratory

A client comes to a health care facility reporting abdominal pain and vomiting. The client's spouse informs the nurse that the client went out for dinner the previous night. The report that the client went out for dinner the previous night is example of data from which type of source? a.Secondary b.Quaternary c.Primary d.Tertiary

secondary

full stage of illness

specific signs and symptoms of illness present - can be localized or systemic

The nurse is caring for assigned clients who are all stable. Which client should the nurse see first to minimize the spread of infection? the client placed in contact isolation who was admitted with a draining abdominal wound the client who is 48-hours postsurgical procedure the client admitted with a rash who reports recent exposure to measles the client admitted with diarrhea who tested positive for Escherichia coli (E. coli)

the client who is 48-hours postsurgical procedure

The nursing instructor is teaching students about assessment and the importance of having baseline data when caring for clients. The instructor should inform the students that the best place to get baseline data is: the focus assessment done when admitted to the ER. the client record from the physician's office. the health record from a previous admission. the initial comprehensive client assessment.

the initial comprehensive client assessment.

One of the outcomes that has been identified in the care of a client with a new suprapubic catheter is that he will demonstrate the correct technique for cleaning his insertion site and changing his catheter prior to discharge. When should this outcome be evaluated? when the client is discharged once the primary care physician has written a discharge order throughout the client's hospital admission during the first home health care visit

throughout the client's hospital admission

•Health risk behaviors are

unhealthy behaviors you can change. Four of these health risk behaviors cause much of the illness, suffering, and early death related to chronic diseases and conditions. •Poor nutrition •Lack of exercise or physical activity •Tobacco use •Substance abuse

A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse: attempts to write down everything the client says. reassures the client of good outcomes. agrees with each of the client's statements. uses broad, open statements to communicate with the client.

uses broad, open statements to communicate with the client.

secondary health promotion

•Screening for early detection of diseases with prompt diagnosis and treatment