midterm practice

A nurse is preparing a presentation about hospice care services. Which of the following statements should the nurse plan to make during the presentation? "During hospice care services, the caregiver receives a break from caring for the client for personal time." "Hospice care services keep the family updated on the client's condition." "Hospice care services are initiated when the client has less than 2 years to live." "During hospice care services, the client can receive their IV chemotherapy medications."

"Hospice care services keep the family updated on the client's condition." ~Hospice care services provide comfort and support for the client and their family. The hospice team is responsible for keeping the family updated on the client's condition.

A nurse is teaching about values to a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding? "It is important that the nurse is aware of the client's values." "A nurse's personal values should not influence ethical decisions." "A nurse behaviors and actions are called values." "Value clarification involves maintaining clinical competency."

"It is important that the nurse is aware of the client's values." ~The nurse should honor and respect the client's values. Therefore, it is important for the nurse to be aware of the client's values.

A nurse is providing teaching to a client who has a terminal illness and is considering palliative care services. Which of the following statements by the client indicates an understanding of the teaching? "I will receive help with managing my meals with this service." "I will need to go to a skilled facility to receive these services." "This service provides my caregiver the opportunity to take time for themselves." "This service assists with making me comfortable during my illness."

"This service assists with making e comfortable during my illness." ~The nurse should identify that the client understands the teaching provided. Palliative care services provide comfort and support measures to the client during sickness.

A nurse is teaching a client about using a PCA device for postoperative pain management. Which of the following statements should the nurse make? "Your partner can push the PCA button for you if you are asleep." "You will have control of administering your own pain medication." "A large dose of pain medication is administered with each injection." "The pain medication is delivered into your muscle."

"You will have control of administering your own pain medication." ~PCA devices allow the client to control administration of their own pain medication.

A nurse is caring for a client who has a prescription for morphine 1 to 2 mg subcut every 4 hr PRN for pain. Which of the following actions should the nurse take? Clarify the dosage of the morphine. Administer 2 mg of morphine every 2 hr. Clarify the route of the morphine. Administer up to 2 mg of morphine in 4 hr.

Administer up to 2mg of morphine in 4 hr. ~The nurse should administer the lowest dose first to the client. If the dose is ineffective, the nurse should wait until the medication has peaked before administering another dose, up to the maximum amount in the range prescribed by the provider, or up to 2 mg of morphine in 4 hr.

A nurse is teaching a client who is at risk for osteoporosis. The nurse should instruct the client that which of the following foods is the best source of calcium? Almond milk Low-fat milk Whole milk Soy milk

Almond milk ~The nurse should instruct that almond milk is the best source of calcium because 1 cup of almond milk contains 451 mg of calcium.

A nurse is caring for a client who is receiving a continuous IV through a peripheral intravenous device. The nurse notes the catheter site is warm and painful to touch. Which of the following actions should the nurse take? Place the affected extremity below the level of the client's heart. Slow the IV infusion Apply a warm compress to the IV site. Place a pressure dressing over the IV site.

Apply a warm compress to the IV site. ~The nurse should apply a warm compress to the IV site to decrease inflammation and promote comfort.

A nurse is caring for a client who receiving a continuous infusion through a peripheral IV device. The nurse notes the catheter site is cool, swollen, blanched, and painful to touch. Which of the following actions should the nurse take? Place a pressure dressing over the IV site. Aspirate fluid from the IV cannula. Slow the IV infusion. Place the affected extremity below the level of the client's heart.

Aspirate fluid from the IV cannula. ~The nurse should try to aspirate fluid from the IV cannula to remove any solution that might cause further injury.

A nurse is caring for a client who is scheduled for an elective surgery. The client informs the nurse that they no longer wish to proceed with surgery. Which of the following ethical principles should the nurse uphold for the client? Autonomy Fidelity Veracity Justice

Autonomy ~Autonomy is an ethical principle that refers to the client's right to make their own decisions. The client has a right to refuse treatment or procedures at any time and the nurse should respect and honor the client's decision.

A nurse is caring for a client. Click to highlight the findings that increase the client's susceptibility to infection. To deselect a finding, click on the finding again. Client has a BMI of 16 History of type 2 diabetes mellitus Client is a nonsmoker Hct 47% (37% to 52%) Budesonide 6 mg PO qd

BMI of 16 Type 2 Diabetes mellitus Budesonide 6 mg ~The client's BMI, history of type 2 diabetes mellitus, and corticosteroid prescription increase the client's susceptibility to infection. A client who has an increased susceptibility to infection might have a decreased resistance to infection due to factors such as a depressed immune system, malnutrition, presence of a chronic disease, or a smoking history. The client's nonsmoking status and Hct level do not increase the client's susceptibility to infection.

A nurse is teaching a client who is at risk for hypokalemia. The nurse should instruct the client that which of the following foods is the best source of potassium? Baked potato Banana Avocado Spinach

Baked potato ~The nurse should instruct the client that a baked potato is the best source of potassium because 1 medium baked potato contains 941 mg of potassium.

A nurse is caring for a client who is scheduled for surgery and who reports they smoke cigarettes. The nurse should identify that tobacco use increases the client's risk for which of the following postoperative complications? Blood clots Malignant hyperthermia Bleeding Nausea

Blood clots ~Smoking tobacco increases the risk for blood clots, myocardial infarction, pneumonia, tissue necrosis, and delayed wound healing.

A nurse is caring for a client. For which of the following interprofessional team members should the nurse anticipate a provider's referral? Select all that apply. Case manager Respiratory therapist Diabetes nurse educator Physical therapist Occupational therapist Enterostomal therapy nurse

Case manager Respiratory therapist Physical therapist Occupational therapist ~When analyzing cues, the nurse should anticipate a provider's prescription for referrals to the case manager, respiratory therapist, physical therapist, and occupational therapist. A case manager is required to coordinate the health care team and identify any needs the client may have during admission and prior to discharge. A respiratory therapist is needed to assist with managing the client's asthma and oxygenation. A physical therapist is needed to manage the client's muscle weakness and mobility. An occupational therapist is needed to assist the client in maintaining the client's ADLs.

A charge nurse is teaching a newly licensed nurse the importance of client confidentiality. Which of the following professional standards should the charge nurse refer to in the teaching? Code of Ethics for Nurses American Nurses Association Position Statements Nursing Scope and Standards of Practice Principles of Nursing Practice

Code of Ethics for Nurses ~The charge nurse should include the professional standard of the Code of for Nurses which is part of the American Nurses Association in the teaching. This standard provides behaviors and practices nurses should follow to provide ethical care to clients which can include confidentiality and protecting clients' rights.

A nurse is teaching a newly licensed nurse about informed consent. Which of the following should be included as a responsibility of the nurse in this process? Confirm that the client is competent to sign for the procedure. Discuss the risks of the procedure with the client. Explain alternatives to the procedure to the client. Inform the client about what will occur during the procedure.

Confirm that the client is competent to sign for the procedure. ~The nurse should confirm the client is competent, of legal age, voluntarily giving consent, and has been given adequate information about the procedure.

A nurse is caring for an older adult client. The client has an increased risk for dehydration due to which of the following physiological changes that can occur with aging? Decrease in kidney function. Increase in saliva production. Increase in percentage of body water. Decrease in systolic blood pressure.

Decrease in kidney function. ~Older adult clients can experience a decrease in kidney function which can result in an extracellular fluid volume deficit and dehydration.

A nurse is assessing a client who has chronic kidney disease. Which of the following findings is a manifestation of hyperkalemia? Cerebral edema Hypoactive bowel sounds Decreased deep tendon reflexes Wheezing

Decreased deep tendon reflexes ~Hyperkalemia can cause decreased deep tendon reflexes, paralysis, and dysrhythmias.

A nurse is caring for a client who is experiencing postoperative nausea and vomiting. The nurse should monitor the client for which of the following complications of vomiting? Peripheral edema Dehydration Diarrhea Urinary frequency

Dehydration ~The client is at risk for dehydration and electrolyte imbalance. Therefore, the nurse should monitor the client for hypotension, tachycardia, and reduced urine output.

A nurse is caring for a client who is postoperative. Click to highlight the documentation in the client's medical record that require further action by the nurse? To deselect a finding, click on the finding again. Temperature 37.5° C (99.5° F) Client is difficult to arouse. Respirations 10/min Pulse oximetry 89% on room air Pupils are 3 mm, equal and reactive to light

Difficult to arouse. Respiration 10/min. Pulse Ox 89 on room air.

A nurse is performing a blood pressure screening for a client who has a family history of hypertension. Which of the following concepts is the nurse demonstrating? Holistic health Disease prevention Health education Health promotion

Disease prevention ~The nurse is demonstrating the concept of disease prevention by performing a blood pressure screening for the client who has a family history of hypertension. Through early detection of hypertension, an associated illness such as a stroke might be prevented.

A nurse is assessing a client who is nonverbal for acute pain. Which of the following findings is a manifestation of pain? Constricted pupils Reduced respiratory rate Elevated blood pressure Decreased heart rate

Elevated blood pressure ~Nonverbal manifestations of acute pain can include hypertension, diaphoresis, grimacing, and guarding.

A nurse does not take a client's apical heart rate, but documents that it was taken in the client's electronic health record (EHR). Which of the following terms describes the nurse's actions? Libel Battery Falsification Slander

Falsification ~Documenting false data in a client's EHR is falsification of health records. The nurse willingly documented in the EHR an apical pulse rate without obtaining the client's apical pulse rate. This is considered unprofessional conduct and by the nurse and could lead to disciplinary action.

A nurse is caring for a client who is desiring their wound care to be provided at 1400. The nurse returns at 1400 to perform wound care for the client. Which of the following ethical principles is the nurse demonstrating? Fidelity Veracity Justice Autonomy

Fidelity ~Fidelity is an ethical principle that ensures trust between the client and the nurse by keeping agreements. Nurses should uphold their agreements made with their clients, which builds trust in the nurse-client relationship.

A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as a non-modifiable risk factor for disease? Genetics Smoking Sunbathing Unhealthy diet

Genetics ~The nurse should identify that genetics is a non-modifiable risk factor. Non-modifiable risk factors are findings that cannot be changed and place the client at risk for disease. Other non-modifiable risk factors include age, gender, race, and family history.

A nurse is instructing a client who has heart disease about ways to improve their health such as eating a heart healthy diet. Which of the following concepts is the nurse demonstrating to the client? Primary prevention Health education Health promotion Holistic health

Health promotion ~The nurse is demonstrating the concept of health promotion by instructing the client on ways to improve their health such as eating a heart healthy diet. Other forms of health promotion can include exercise, weight loss, limiting alcohol consumption, and smoking cessation.

A nurse is caring for a client. A nurse is reviewing the client's medical record. Which of the following findings places the client at risk for heart disease? Select all that apply. History of hypertension History of smoking Daily exercise History of rheumatoid arthritis Cholesterol level Fasting glucose level

History of hypertension History of smoking Cholesterol level ~History of hypertension is correct. Hypertension is associated with arterial wall thickening and increased peripheral resistance which can lead to heart disease. History of smoking is correct. Nicotine causes vasoconstriction, which can increase blood pressure and heart rate, and lead to heart disease. Daily exercise is incorrect. Daily exercise can increase peripheral circulation, reduce stress, and strengthen cardiac muscle, which can reduce the risk of heart disease. History of rheumatoid arthritis is incorrect. A history of rheumatoid arthritis places the client at risk for a fall, but it is not a risk factor for heart disease. Cholesterol level is correct. The client's cholesterol level is greater than the expected reference range which places the client at risk for heart disease. Hyperlipemia can result in restrictive blood flow to cardiac arteries. Fasting glucose level is incorrect. The client's fasting glucose is within the expected reference range and does not increase the client's risk for heart disease.

A nurse is planning discharge for a client who has a sacral pressure injury and has a prescription for daily dressing changes. Which of the following resource referrals should the nurse anticipate from the provider for this client? Home care Assisted living Long-term care Hospice care

Home care ~Home care provides nursing services for the client in their home such as wound care, tube feedings, and administration of antibiotics. The nurse should anticipate a referral for the client to receive home care services to manage their pressure injury.

A nurse is caring for a client who is receiving an IV infusion of dextrose 10% in water. The nurse should monitor the client for which of the following adverse effects? Hypercalcemia Hypovolemia Hyperglycemia Hypokalemia

Hyperglycemia ~The nurse should infuse the IV slowly and monitor the client for hyperglycemia.

A nurse is caring for a client who is scheduled for a surgical procedure. Select the 3 findings that require immediate follow-up. INR Blood pressure Hgb Preoperative medication WBC count Pulse oximetry

INR Preoperative Medication (warfarin = risk for bleeding) WBC count ~When recognizing cues, the nurse should identify that the client's INR, combined with taking warfarin the morning of the procedure, places the client at risk for bleeding. The client's WBC count is greater than the expected reference range, which places the client at risk for an infection. Therefore, these findings should be reported to the provider.

A nurse has completed the planning step of the nursing process for a client who has an acid-base imbalance. Which of the following steps should the nurse take next? Assessment Analysis Evaluation Implementation

Implementation ~The next action the nurse should take using the nursing process is to implement the plan. The nurse should move into the implementation phase of the nursing process following the planning stage. The plan of care is implemented during the implementation stage.

A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse expect? Numbness of fingers Lethargy Abdominal pain Dry skin

Lethargy ~Manifestations of respiratory acidosis can include anxiety, confusion, and lethargy.

A nurse is caring for a client. A nurse is reviewing a fall risk assessment for a client. Which of the following findings places the client at risk for a fall? Select all that apply. Grab bar in bathroom Macular degeneration Throw rugs in kitchen Uses a cane to ambulate Electrical cord on floor over walkway

Macular degeneration Throw rugs in kitchen Electrical cord on floor over walkway ~When analyzing cues, the nurse should identify that macular degeneration, electrical cord on floor over walkway, and throw rugs in the kitchen are findings that increases the client's risk for falls. Macular degeneration is a disorder that causes deterioration of the macula which results in visual impairment. An electrical cord on floor over a walkway is a hazard that could result in a potential fall. Throw rugs in the kitchen are a potential hazard because the rugs are not secured to the floor and the client can receive a potential fall injury.

A nurse is assessing a client who has diarrhea. Which of the following findings is a manifestation of hypokalemia? Cerebral edema Hyperactive bowel sounds Hypertension Muscle weakness

Muscle weakness ~Hypokalemia can cause muscle weakness, hypotension, and dysrhythmias.

A nurse is teaching a newly licensed nurse about ethical principles. The nurse should include that working to not cause harm to a client, while trying to achieve the best possible outcome, is an example of which of the following ethical principles? Justice Fidelity Autonomy Nonmaleficence

Nonmaleficence ~Nonmaleficence is providing care for a client in a way to avoid causing harm or hurt while trying to achieve the best possible outcome. Providing scheduled pain medication for a client who is having pain, without causing harm to the client, is an example of nonmaleficence.

A nurse is reviewing the medical history on a client who is preoperative for surgery. Which of the following findings places the client at risk for a postoperative complication? BMI 24 Glucose level 75 mg/dL Fractured ankle Obstructive sleep apnea

Obstructive sleep apnea ~Obstructive sleep apnea places the client at risk for postoperative airway obstruction.

A nurse is caring for a client who has diabetic ketoacidosis and hypoxia. Which of the following actions should the nurse take first? Obtain a prescription to check the client's glucose level. Obtain a prescription to administer intravenous fluids. Obtain a prescription to administer insulin. Obtain a prescription for supplemental oxygen.

Obtain a prescription for supplemental oxygen. ~The first action the nurse should take when using the airway, breathing, circulation approach to client care is to obtain a prescription for supplemental oxygen. Supplemental oxygen is indicated in clients who have hypoxia to improve oxygenation.

A nurse is teaching a class about pain management in older adult clients. Which of the following information should the nurse include? Older adult clients frequently underreport pain. Clients who are cognitively impaired do not feel pain. Pain perception decreases with aging. Opioids should not be used in older adult clients.

Older adult clients frequently underreport pain. ~Older adult clients often underreport pain. Some reasons for underreporting pain can include not wanting to bother the nurse, afraid to be labeled as a complainer, or they might feel that pain is a natural outcome of growing old.

A nurse is caring for a client who has metabolic alkalosis. Which of the following actions should the nurse take? Have the client breath into a paper bag. Encourage the client to breath slowly. Place the client on seizure precautions. Plan to administer sodium bicarbonate to the client.

Place the client on seizure precautions. ~The nurse should initiate seizure precautions because the client who has metabolic alkalosis is at risk for seizure activity.

A newly hired nurse is preparing to remove a client's IV catheter. Which of the following actions should the nurse take? Find an article in a nursing journal that is less than 5 years old on how to remove IV catheters. Ask an assistive personnel (AP) to verbalize the steps for removing an IV catheter. Research how to remove an IV catheter from the internet. Review the facility's policies and procedures manual about removing IV catheters.

Review the facility's policies and procedures manual about removing IV catheters. ~Reviewing the policies and procedures manual before performing a skill provides the nurse with best practice guidelines that promotes safety. These manuals provide information such as who can perform the procedure, equipment needed, and the steps to follow for the procedure.

A nurse is providing care to a client. Prior to exiting the client's room, the nurse ensures the client's bed is locked and their call light is within reach. Which of the following QSEN competencies is the nurse demonstrating? Patient-centered care Teamwork and collaboration Quality improvement Safety

Safety ~The nurse is demonstrating the competency of safety from the QSEN competency guidelines by ensuring the client's bed is locked and their call light is within reach. These actions reduce the risk of client injury.

An acute care nurse is caring for a client who is postoperative and has a prescription for physical therapy 2-3 times per day for 2 weeks. Which of the following resources should the nurse anticipate that the client will require upon discharge? Assisted living Skilled nursing Palliative care Long-term care

Skilled nursing ~A skilled nursing facility provides rehabilitation services such as occupational and physical therapy. The nurse should anticipate that the client will be transferred to this type of facility.

A nurse is teaching a newly licensed nurse about pain. Which of the following is an example of nociceptive pain? Post-herpetic neuralgia Diabetic neuropathy Phantom limb pain Strained muscle

Strained Muscle ~Nociceptive pain is pain that is caused by somatic origin or visceral origin. Somatic pain occurs due to damage to bone, joints, muscle, skin, or connective tissue. Visceral pain occurs due to damage to a visceral organ, such as the gastrointestinal tract or pancreas.

A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as a modifiable risk factor for developing a disease? Age Genetics Family history Sunbathing

Sunbathing ~The nurse should identify sunbathing as a modifiable risk factor for cancer. Modifiable risk factors are behaviors or a lifestyle that can be changed to improve health.

A nurse is teaching a newly licensed nurse about pain. Which of the following is an example of acute pain? Surgical incision Peripheral neuropathy Rheumatoid arthritis Fibromyalgia

Surgical incision ~A surgical incision causes a short-term, anticipated pain that lasts less than 6 months.

A nurse is caring for a client. Click to highlight the findings at 1100, that require follow-up. To deselect a finding, click on the finding again. T 38.6° C (101.5°F), oral. BP 112/54 mm Hg, supine Apical HR 108/min R 22/min Pulse oximetry 90% on 40% O2 via face mask Mucous membranes pink.

T 38.6° C (101.5°F), oral. Apical HR 108/min ~The client's temperature and heart rate has worsened and require follow-up by the nurse. The client's temperature has increased indicating the interventions were not effective in lowering the client's temperature. The client's heart rate has increased which is a manifestation of increased metabolic rate. The client's blood pressure is unchanged. The client's blood pressure is unchanged because it continues to be within the expected reference range indicating adequate circulation. The client's respiratory rate, pulse oximetry, and mucous membranes color have improved. The client's respiratory rate has decreased indicating the interventions were effective in improving the client's respirations. The client's pulse oximetry has increased indicating the interventions were effective in improving the client's oxygenation. The client's mucous membrane color has improved indicating the interventions were effective in improving the client's oxygenation.

A nurse is assessing a client for manifestations of pain. Which of the following findings is an objective indicator of pain? The client rates their pain as an 8 on a scale of 0 to 10. The client reports a burning sensation. The client grimaces when they move. The client states the pain is located on their abdomen.

The client grimaces when they move. ~Objective indicators of pain are determined by manifestations the nurse can observe or measure. Grimacing is an objective indicator of pain.

A charge nurse is reviewing the documentation completed by a newly licensed nurse. Which of the following entries should the charge nurse recommend for revision? The client demonstrated proper technique when drawing up 8 units of insulin. The client stated, "I struggle to see those little lines on the syringe." The client seems to be more comfortable performing self-administration of insulin. The client's FBS was 95 mg/dl

The client seems to be more comfortable performing self-administration of insulin. ~This statement reflects the nurse's opinion and should be revised. The American Nurses Association standards for documentation state that entries into a client's medical record must be factual, accurate, complete, timely and organized.

A nurse is writing a teaching plan using the Specific, Measurable, Attainable, Relevant, and Timed outcome (SMART) goals for a client who is learning to walk with crutches. Click to highlight the timed components of the SMART outcome goals. To deselect a finding, click on the finding again. The client will teach back information about safe crutch walking on day 1. The client will demonstrate safe crutch walking. The client will not lean on the crutches to support their body weight. The client will ambulate 5 feet in one day. The client will walk 10 feet by day 2. The client will walk 20 feet by day 3. The client will explain 4 principles of crutch safety. The client will explain how to keep crutches in safe condition.

The client will teach back information about safe crutch walking on day 1. The client will ambulate 5 feet in one day. The client will walk 10 feet by day 2. The client will walk 20 feet by day 3. ~When taking actions, the nurse should identify that the timed component of SMART outcome goals are measurable outcomes based upon a specific time frame by which the client should accomplish the outcome. Day1, in one day, by day 2, and by day 3, are all measurable time frames to assist the nurse in evaluating whether outcome goals are achieved.

A nurse is caring for a client who is scheduled for a surgical procedure. The nurse is reviewing the client's electronic medical record. Which of the following findings places the client at risk for a surgical complication? Select all that apply. ype 2 diabetes mellitus Prednisone Glucose level Metformin Smoking history WBC count

Type 2 diabetes mellitus Prednisone Smoking history ~When analyzing cues, the nurse should identify that type 2 diabetes mellitus, smoking history, and prednisone use place the client at risk for surgical complications, such as for delayed wound healing and infection. Smoking cigarettes also increase the client's risk for atelectasis and pneumonia.

A nurse is caring for a client. Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing BLANK due to BLANK

pulmonary embolism due to possible deep vein thrombosis ~When analyzing cues, the nurse should note that the client is at risk for developing a pulmonary embolism due to possible deep vein thrombosis. The client reports they just returned from an 8-hr car trip. Extended periods of immobility place the client at an increased risk for a deep vein thrombosis which can lead to a pulmonary embolism. Manifestations of a deep vein thrombosis include unilateral edema, pain, and redness, which often develops in the lower extremities.