Module 6 Test Bank
After teaching a client about advance directives, a nurse assesses the client's understanding. Which statement indicates that the client correctly understands the teaching? a. "An advance directive will keep my children from selling my home when I'm old." b. "An advance directive will be completed as soon as I'm incapacitated and can't think for myself." c. "An advance directive will specify what I want done when I can no longer make decisions about health care." d. "An advance directive will allow me to keep my money out of the reach of my family."
"An advance directive will specify what I want done when I can no longer make decisions about health care."
A nurse plans care for a client who is nearing end of life. Which question will the nurse ask when developing this client's plan of care? a. "Is your advance directive up to date and notarized?" b. "Do you want to be at home at the end of your life?" c. "Would you like a physical therapist to assist you with range-of-motion activities?" d. "Have your children discussed resuscitation with your primary health care provider?"
"Do you want to be at home at the end of your life?"
A nurse teaches a client who is considering being admitted to hospice. Which statement does the nurse include in this client's teaching? a. "Hospice admission has specific criteria. You may not be a viable candidate, so we will look at alternative plans for your discharge." b. "Hospice care focuses on a holistic approach to health care. It is not designed to hasten death, but rather to relieve symptoms." c. "Hospice care will not help with your symptoms of depression. I will refer you to the facility's counseling services instead." d. "You seem to be experiencing some difficulty with this stage of the grieving process. Let's talk about your feelings."
"Hospice care focuses on a holistic approach to health care. It is not designed to hasten death, but rather to relieve symptoms."
A nurse teaches a community health class about water safety. Which statement by a participant indicates that additional teaching is needed? a. "I can go swimming all by myself because I am a certified lifeguard." b. "I cannot leave my toddler alone in the bathtub for even a minute." c. "I will appoint one adult to supervise the pool at all times during a party." d. "I will make sure that there is a phone near my pool in case of an emergency."
"I can go swimming all by myself because I am a certified lifeguard."
After teaching a client who expressed concern about a rash located beneath her breast, a nurse assesses the client's understanding. Which statement indicates the client has a good understanding of this condition? a. "This rash is probably due to fluid overload." b. "I need to wash this daily with antibacterial soap." c. "I can use powder to keep this area dry." d. "I will schedule a mammogram as soon as I can."
"I can use powder to keep this area dry."
The nurse is teaching a family member about various types of complementary therapies that might be effective for relieving the dying client's anxiety and restlessness. Which statement made by the family member indicates understanding of the nurse's teaching? a. "Maybe we should just hire an around-the-clock sitter to stay with Grandmother." b. "I have some of her favorite hymns on a CD that I could bring for music therapy." c. "I don't think that she'll need pain medication along with her herbal treatments." d. "I will burn therapeutic incense in the room so we can stop the anxiety pills."
"I have some of her favorite hymns on a CD that I could bring for music therapy."
A nurse is assessing a client who has a recent diagnosis of melanoma for understanding of treatment choices. What statement by the client indicates good understanding of the information? a. "Dermabrasion or chemical peels can be done in the office." b. "I may need lymph node resection during Mohs surgery." c. "This needs only a small excision with local anesthetic." d. "After surgery I will need 8 weeks of radiation therapy."
"I may need lymph node resection during Mohs surgery."
An intensive care nurse discusses withdrawal of care with a client's family. The family expresses concerns related to discontinuation of therapy. How will the nurse respond? a. "I understand your concerns, but in this state, discontinuation of care is not a form of active euthanasia." b. "You will need to talk to the primary health care provider because I am not legally allowed to participate in the withdrawal of life support." c. "I realize this is a difficult decision. Discontinuation of therapy will allow the client to die a natural death." d. "There is no need to worry. Most religious organizations support the client's decision to stop medical treatment."
"I realize this is a difficult decision. Discontinuation of therapy will allow the client to die a natural death."
A nurse is caring for a dying client. The client's spouse states, "I think he is choking to death." How would the nurse respond? a. "Do not worry. The choking sound is normal during the dying process." b. "I will administer more morphine to keep your spouse comfortable." c. "I can ask the respiratory therapist to suction secretions out through his nose." d. "I will have another nurse assist me to turn your spouse onto the side."
"I will have another nurse assist me to turn your spouse onto the side."
A primary health care provider prescribes diazepam to a client who was bitten by a black widow spider. The client asks, "What is this medication for?" How does the nurse respond? a. "This medication is an antivenom for this type of bite." b. "It will relieve your muscle rigidity and spasms." c. "It prevents respiratory difficulty from excessive secretions." d. "This medication will prevent respiratory failure."
"It will relieve your muscle rigidity and spasms."
A nurse is caring for a client who is terminally ill. The client's spouse states, "I am concerned because he does not want to eat." How does the nurse respond? a. "Let him know that food is available if he wants it, but do not insist that he eat." b. "A feeding tube can be placed in the nose to provide important nutrients." c. "Force him to eat even if he does not feel hungry, or he will die sooner." d. "He is getting all the nutrients he needs through his intravenous catheter."
"Let him know that food is available if he wants it, but do not insist that he eat."
A nurse assesses an older client who has two skin lesions on the chest. Each lesion is the size of a nickel, flat, and darker in color than the rest of the client's skin. What does the nurse tell the client regarding these lesions? a. "Monitor these spots for any changes." b. "You don't need to worry about these." c. "I will ask for a dermatology referral for you." d. "We need to schedule you for a skin biopsy."
"Monitor these spots for any changes."
After teaching a client how to prevent altitude-related illnesses, a nurse assesses the client's understanding. Which statement indicates that the client needs additional teaching? a. "If my climbing partner can't think straight, we should descend to a lower altitude." b. "I will ask my primary health care provider about medications to help prevent acute mountain sickness." c. "My partner and I will plan to sleep at a higher elevation to acclimate more quickly." d. "I will drink plenty of fluids to stay hydrated while on the mountain."
"My partner and I will plan to sleep at a higher elevation to acclimate more quickly."
A nurse cares for an older adult client who has a chronic skin disorder. The client states, "I have not been to church in several weeks because of the discoloration of my skin." How will the nurse respond? a. "I will consult the chaplain to provide you with spiritual support." b. "You do not need to go to church; God is everywhere." c. "Tell me more about your concerns related to your skin." d. "Religious people are nonjudgmental and will accept you."
"Tell me more about your concerns related to your skin."
A nurse discusses palliative care with a client and the client's family. A family member expresses concern that the loved one will receive only custodial care. How will the nurse respond? a. "The goal of palliative care is to provide the greatest degree of comfort possible and help the dying person enjoy whatever time is left." b. "Palliative care will release you from the burden of having to care for someone in the home. It does not mean that curative treatment will stop." c. "A palliative care facility is like a nursing home and costs less than a hospital because only pain medications are given." d. "Your relative is unaware of her surroundings and will not notice the difference between her home and a palliative care facility."
"The goal of palliative care is to provide the greatest degree of comfort possible and help the dying person enjoy whatever time is left."
A nurse assesses a client who has inflamed soft-tissue folds around the nail plates. Which question will the nurse ask to elicit useful information about the possible condition? a. "What do you do for a living?" b. "Are your nails professionally manicured?" c. "Do you have diabetes mellitus?" d. "Have you had a recent fungal infection?"
"What do you do for a living?"
A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which question will the nurse ask first? a. "Are you using lotion on your skin?" b. "Do you have a family history of this?" c. "Do your arms itch?" d. "What medications are you taking?"
"What medications are you taking?"
A nurse is caring for a dying client whose adult child confides frequent crying episodes to the nurse. How does the nurse respond? a. "It's normal. Most people move on within a few months." b. "Whenever you start to cry, distract yourself with pleasant thoughts of your parent." c. "You should try not to cry. Your parent will be in a better place soon." d. "Your feelings are completely normal and may continue for a long time."
"Your feelings are completely normal and may continue for a long time."
A nurse is triaging clients in the emergency department (ED). Which client would the nurse prioritize to receive care first? a. A 22 year old with a painful and swollen right wrist b. A 45 year old reporting chest pain and diaphoresis c. A 60 year old reporting difficulty swallowing and nausea d. An 81 year old, respiratory rate 28 breaths/min and temperature of 101° F (38.8° C)
45 year old reporting chest pain and diaphoresis
An emergency department nurse is triaging victims of a multi-casualty event. Which client would receive care first? a. A 30-year-old distraught mother holding her crying child b. A 65-year-old conscious male with a head laceration c. A 26-year-old male who has pale, cool, clammy skin d. A 48 year old with a simple fracture of the lower leg
A 26-year-old male who has pale, cool, clammy skin
A nurse is triaging clients in the emergency department. Which client would the nurse classify as "nonurgent?" a. A 44 year old with chest pain and diaphoresis b. A 50 year old with chest trauma and absent breath sounds c. A 62 year old with a simple fracture of the left arm d. A 79 year old with a temperature of 104° F (40.0° C)
A 62 year old with a simple fracture of the left arm
A nurse is triaging clients in the emergency department. Which client would be considered "urgent"? a. A 20-year-old female with a chest stab wound and tachycardia b. A 45-year-old homeless man with a skin rash and sore throat c. A 75-year-old female with a cough and a temperature of 102° F (38.9° C) d. A 50-year-old male with new-onset confusion and slurred speech
A 75-year-old female with a cough and a temperature of 102° F (38.9° C)
While at a public park, a nurse encounters a person immediately after a bee sting. The person's lips are swollen, and wheezes are audible. What action would the nurse take first? a. Elevate the site and notify the person's next of kin. b. Remove the stinger with tweezers and encourage rest. c. Administer diphenhydramine and apply ice. d. Administer an epinephrine autoinjector and call 911.
Administer an epinephrine autoinjector and call 911.
An emergency department nurse cares for a middle-age mountain climber who is confused, ataxic, and exhibits impaired judgement. After administering oxygen, which intervention would the nurse implement next? a. Administer dexamethasone. b. Complete a mini mental state examination. c. Prepare the client for computed tomography of the brain. d. Request a psychiatric consult.
Administer dexamethasone.
A primary health care provider prescribes a rewarming bath for a client who presents with Grade 3 frostbite. What action would the nurse take prior to starting this treatment? a. Administer intravenous morphine. b. Wrap the limb with a compression dressing. c. Massage the frostbitten areas. d. Assess the limb for compartment syndrome.
Administer intravenous morphine.
A middle-age mountain hiker is admitted to the emergency department exhibiting a cough with pink, frothy sputum and cyanosis of lips and nail beds. What priority action would the nurse implement? a. Administer acetazolamide. b. Administer oxygen via a nonrebreather mask. c. Complete a thorough pulmonary assessment. d. Obtain arterial blood gas (ABG) specimen for analysis.
Administer oxygen via a nonrebreather mask
A middle-age mountain hiker is admitted to the emergency department exhibiting a cough with pink, frothy sputum and cyanosis of lips and nail beds. What priority action would the nurse implement? a. Administer acetazolamide. b. Administer oxygen via a nonrebreather mask. c. Complete a thorough pulmonary assessment. d. Obtain arterial blood gas (ABG) specimen for analysis.
Administer oxygen via a nonrebreather mask.
A client presents to the emergency department after prolonged exposure to the cold. The client is difficult to arouse and speech is incoherent. What action would the nurse take first? a. Reposition the client into a prone position. b. Administer warmed intravenous fluids to the client. c. Wrap the client's extremities in warm blankets. d. Initiate extracorporeal rewarming via hemodialysis.
Administer warmed intravenous fluids to the client.
A nurse is caring for a terminally ill client who has just died in a hospital setting with family members at the bedside. Which action will the nurse take first? a. Call for emergency assistance so that resuscitation procedures can begin. b. Ask family members if they would like to spend time alone with the client. c. Ensure the primary health care provider completed the death certificate. d. Request family members to prepare the client's body for the funeral home.
Ask family members if they would like to spend time alone with the client
The emergency department team is performing cardiopulmonary resuscitation on a client when the client's spouse arrives. Which action would the nurse take first? a. Request that the client's spouse sit in the waiting room. b. Ask the spouse if he or she wishes to be present during the resuscitation. c. Suggest that the spouse begin to pray for the patient. d. Refer the client's spouse to the hospital's crisis team.
Ask the spouse if he or she wishes to be present during the resuscitation.
Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action would the nurse take first? a. Assess that the client is breathing adequately. b. Insert a large-bore intravenous line. c. Place the client on a cardiac monitor. d. Assess for the best neurologic response.
Assess that the client is breathing adequately
A client has been brought to the emergency department after being covered in fertilizer after an explosion and fire at a warehouse. What action by the nurse is best? a. Assess the client's airway. b. Irrigate the client's skin. c. Brush any visible dust off the skin. d. Call poison control for guidance
Assess the client's airway.
A client admitted to the emergency department following a lightning strike. What is the priority assessment the nurse focuses on? a. Cardiopulmonary b. Integumentary c. Peripheral vascular d. Renal
Cardiopulmonary
A nurse assesses a client recently bitten by a coral snake. Which assessment would the nurse complete first? a. Unilateral peripheral swelling b. Clotting times c. Cardiopulmonary status d. Electrocardiogram rhythm
Cardiopulmonary status
An emergency department nurse is caring for a client who has died from a suspected homicide. Which action does the nurse take? a. Remove all tubes and wires in preparation for the medical examiner. b. Limit the number of visitors to minimize the family's trauma. c. Consult the bereavement committee to follow up with the grieving family. d. Communicate the client's death to the family in a simple and concrete manner.
Communicate the client's death to the family in a simple and concrete manner.
While on a camping trip, a nurse cares for an adult client who had a drowning incident in a lake and is experiencing agonal breathing with a palpable pulse. What action would the nurse take first? a. Deliver rescue breaths. b. Wrap the client in dry blankets. c. Assess for signs of bleeding. d. Check for a carotid pulse.
Deliver rescue breaths.
What is the primary goal of a triage system used by the nurse with clients presenting to the emergency department? a. Determine the acuity of the client's condition to determine priority of care. b. Assess the status of the airway, breathing, circulation, or presence of deficits. c. Determine whether the client is responsive enough to provide needed information. d. Evaluate the emergency department's resources to adequately treat the patient.
Determine the acuity of the client's condition to determine priority of care.
During skin inspection, the nurse observes lesions with wavy borders that are widespread across the client's chest. Which descriptors will the nurse use to document these observations? a. Clustered and annular b. Linear and circinate c. Diffuse and serpiginous d. Coalesced and circumscribed
Diffuse and serpiginous
A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action would the nurse take prior to providing advanced cardiac life support? a. Contact the on-call orthopedic surgeon. b. Don personal protective equipment. c. Notify the Rapid Response Team. d. Obtain a complete history from the paramedic.
Don personal protective equipment.
An emergency department nurse assesses a client admitted after a lightning strike. The client is awake but somewhat confused. Which assessment would the nurse complete first? a. Electrocardiogram (ECG) b. Wound inspection c. Creatinine kinase d. Computed tomography of head
Electrocardiogram (ECG)
A nurse is caring for a client with an electrical burn. The client has entrance wounds on the hands and exit wounds on the feet. What information is most important to include when planning care? a. The client may have memory and cognitive issues postburn. b. Everything between the entry and exit wounds can be damaged. c. The respiratory system requires close monitoring for signs of swelling. d. Electrical burns increase the risk of developing future cancers.
Everything between the entry and exit wounds can be damaged.
An emergency department nurse assesses a client who has been raped. With which health care team member would the nurse collaborate when planning this client's care? a. Primary health care provider b. Case manager c. Forensic nurse examiner d. Psychiatric crisis nurse
Forensic nurse examiner
A nurse assesses a client and identifies that the client has pale conjunctivae. Which focused assessment will the nurse complete next? a. Partial thromboplastin time b. Hemoglobin and hematocrit c. Liver enzymes d. Basic metabolic panel
Hemoglobin and hematocrit
The nurse reads on a chart that a client has lichenification. What assessment finding confirms this description? a. Increased skin thickness b. Excessive facial hair c. Purple skin patches d. Tightly stretched skin
Increased skin thickness
A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion does the nurse evaluate first? a. Beige freckles on the backs of both hands. b. Irregular mole with multiple colors on the leg. c. Large cluster of pustules in the right axilla. d. Thick, reddened papules covered by white scales.
Irregular mole with multiple colors on the leg.
A hospice nurse is caring for a variety of clients who are dying. Which end-of-life and death ritual is paired with the correct religion? a. Roman Catholic—autopsies are not allowed except under special circumstances. b. Christian—upon death, a religious leader should perform rituals of bathing and wrapping the body in cloth. c. Judaism—a person who is extremely ill and dying should not be left alone. d. Islam—an ill or a dying person should receive the Sacrament of the Sick.
Judaism—a person who is extremely ill and dying should not be left alone.
A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center? a. Level I—located within remote areas and provides advanced life support within resource capabilities b. Level II—located within community hospitals and provides care to most injured clients c. Level III—located in rural communities and provides only basic care to clients d. Level IV—located in large teaching hospitals and provides a full continuum of trauma care for all clients.
Level II—located within community hospitals and provides care to most injured clients
An emergency department nurse is caring for a client who is homeless. Which action would the nurse take to gain the client's trust? a. Speak in a quiet and monotone voice. b. Avoid eye contact with the patient. c. Listen to the client's concerns and needs. d. Ask security to store the client's belongings.
Listen to the client's concerns and needs.
A nurse assesses a client admitted with a brown recluse spider bite. Which assessment does the nurse perform to identify complications of this bite? a. Ask the client about pruritus at the bite site. b. Inspect the bite site for a bluish purple vesicle. c. Assess the extremity for redness and swelling. d. Monitor the client's temperature every 4 hours.
Monitor the client's temperature every 4 hours
A nurse is caring for a client who has lung cancer and is dying. Which prescription does the nurse question? a. Morphine 10 mg sublingual every 6 hours PRN for pain level greater than 5 b. Albuterol metered dose inhaler every 4 hours PRN for wheezes c. Atropine solution 1% sublingual every 4 hours PRN for excessive oral secretions d. Sodium biphosphate enema once a day PRN for impacted stool
Morphine 10 mg sublingual every 6 hours PRN for pain level greater than 5
An elderly client who has fallen from a roof is transported to the emergency department by ambulance. The client was unconscious at the scene but is conscious on arrival and is triaged as urgent. What is the priority assessment the nurse includes during the primary survey of the patient? a. A full set of vital signs b. Cardiac rhythm c. Neurologic status d. Client history
Neurologic status
A nurse cares for a dying client. Which manifestation of dying does the nurse treat first? a. Anorexia b. Pain c. Nausea d. Hair loss
Pain
A nurse assesses an older adult client with the skin disorder shown below: How will the nurse document this finding? a. Petechiae b. Ecchymoses c. Actinic lentigo d. Senile angiomas
Petechiae
An emergency department (ED) case manager is consulted for a client who is homeless. Which intervention would the case manager provide? a. Communicate client needs and restrictions to support staff. b. Prescribe low-cost antibiotics to treat community-acquired infection. c. Provide referrals to subsidized community-based health clinics. d. Offer counseling for substance abuse and mental health disorders.
Provide referrals to subsidized community-based health clinics.
A nurse assesses a client who has open skin lesions. Which action by the nurse is most important? a. Put on gloves. b. Ask the client about his or her occupation. c. Assess the client's pain. d. Obtain vital signs.
Put on gloves.
A nurse assesses a client who is dying. Which sign or symptoms does the nurse assess to determine whether the client is near death? a. Level of consciousness b. Respiratory rate c. Bowel sounds d. Pain level on a 0-10 scale
Respiratory rate
On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, and blood pressure 106/66 mm Hg. What action would the nurse take? a. Encourage the client to drink cool water or sports drinks. b. Start an intravenous line and infuse 0.9% saline solution. c. Administer acetaminophen (Tylenol) 650 mg orally. d. Encourage rest and reassess in 15 minutes.
Start an intravenous line and infuse 0.9% saline solution.
A nurse plans care for a client admitted with a snakebite to the right leg. With whom would the nurse collaborate? a. The facility's neurologist b. The poison control center c. The physical therapy department d. A herpetologist (snake specialist)
The poison control center
While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action would the nurse take first? a. Apply oxygen via nasal cannula. b. Administer intravenous 0.9% saline solution. c. Transfer the client to a negative-pressure room. d. Obtain a sputum culture and sensitivity.
Transfer the client to a negative-pressure room.
While assessing a client, a nurse detects a bluish tinge to the client's palms, soles, and mucous membranes. Which action will the nurse take next? a. Ask the client about current medications he or she is taking. b. Use pulse oximetry to assess the patient's oxygen saturation. c. Auscultate the patient's lung fields for adventitious sounds. d. Palpate the patient's bilateral radial and pedal pulses.
Use pulse oximetry to assess the patient's oxygen saturation.
A nurse teaches a client who has severe allergies ways to prevent insect bites. Which statements does the nurse include in this client's teaching? (Select all that apply.) a. "Consult an exterminator to control bugs in and around your home." b. "Do not swat at insects or wasps." c. "Wear sandals whenever you go outside." d. "Keep your prescribed epinephrine autoinjector in a bedside drawer." e. "Use screens in your windows and doors to prevent flying insects from entering." f. "Identify and remove potential nesting sites in your yard."
a. "Consult an exterminator to control bugs in and around your home." b. "Do not swat at insects or wasps." e. "Use screens in your windows and doors to prevent flying insects from entering." f. "Identify and remove potential nesting sites in your yard."
A client has multiple lesions all over the body and a family history of skin cancer. The nurse teaches the client to perform a total skin self-examinations on a monthly basis. Which statements will the nurse include in this patient's teaching? (Select all that apply.) a. "Look for asymmetry of shape and irregular borders." b. "Assess for color variation within each lesion." c. "Examine the distribution of lesions over a section of the body." d. "Monitor for edema or swelling of tissues." e. "Focus your assessment on skin areas that itch." f. "Report any lesions that change over time in any way."
a. "Look for asymmetry of shape and irregular borders." b. "Assess for color variation within each lesion." f. "Report any lesions that change over time in any way."
A nurse is teaching a wilderness survival class. Which statements would the nurse include about the prevention of hypothermia and frostbite? (Select all that apply.) a. "Wear synthetic clothing instead of cotton to keep your skin dry." b. "Drink plenty of fluids. Brandy can be used to keep your body warm." c. "Remove your hat when exercising to prevent overheating." d. "Wear sunglasses to protect skin and eyes from harmful rays." e. "Know your physical limits. Come in out of the cold when limits are reached." f. "Change your gloves and socks if they become wet."
a. "Wear synthetic clothing instead of cotton to keep your skin dry." d. "Wear sunglasses to protect skin and eyes from harmful rays." e. "Know your physical limits. Come in out of the cold when limits are reached." f. "Change your gloves and socks if they become wet."
The nurse in the emergency department would arrange to transfer which burned clients to a burn center? (Select all that apply.) a. 15% partial-thickness burn b. Lightening injury c. 7% partial-thickness burn d. History of pulmonary edema e. Healthy 67 year old f. 4% partial-thickness burn to perineum
a. 15% partial-thickness burn b. Lightening injury d. History of pulmonary edema e. Healthy 67 year old f. 4% partial-thickness burn to perineum
An emergency department nurse plans care for a client who is admitted with heat stroke. Which interventions does the nurse include in this patient's plan of care? (Select all that apply.) a. Administer oxygen via mask or nasal cannula. b. Administer ibuprofen, an antipyretic medication. c. Apply cooling techniques until core body temperature is less than 101° F (38.3° C). d. Infuse 0.9% sodium chloride via a large-bore intravenous cannula. e. Obtain baseline serum electrolytes and cardiac enzymes. f. Insert an indwelling urinary catheter for urine output measurements.
a. Administer oxygen via mask or nasal cannula. d. Infuse 0.9% sodium chloride via a large-bore intravenous cannula. e. Obtain baseline serum electrolytes and cardiac enzymes.
A client resuscitated after drowning is admitted to the emergency department. What assessment findings does the nurse recognize as symptoms of a drowning? (Select all that apply.) a. Bilateral crackles b. Bradycardia c. Cyanosis of the lips d. Hypotension e. Flushed, diaphoretic skin
a. Bilateral crackles b. Bradycardia c. Cyanosis of the lips d. Hypotension
A nurse admits an older adult client to the hospital. Which criteria does the nurse use to determine if the client can make his or her own medical decisions? (Select all that apply.) a. Can communicate treatment preferences. b. Is able to read and write at an eighth-grade level. c. Is oriented enough to understand information provided. d. Can evaluate and deliberate information. e. Has completed an advance directive. f. The family states the client can make decisions.
a. Can communicate treatment preferences. c. Is oriented enough to understand information provided. d. Can evaluate and deliberate information.
Which assessment findings would indicate to the nurse that a client has suffered from a heat stroke? (Select all that apply.) a. Confusion and bizarre behavior b. Headache and fatigue c. Hypotension d. Presence of perspiration e. Tachycardia and tachypnea f. Body temperature more than 104° F (40° C)
a. Confusion and bizarre behavior c. Hypotension e. Tachycardia and tachypnea f. Body temperature more than 104° F (40° C)
A nurse is in charge of a first-aid tent at an all-day outdoor sports event on a hot and humid day. A participant comes to the tent reporting a headache, weakness, and nausea. What actions would the nurse take? (Select all that apply.) a. Have the client lie down in a cool place. b. Force fluids with large quantities of plain water. c. Administer acetaminophen and send home. d. Apply cold packs to neck, arm pits, and groin. e. Encourage drinking a sports drink. f. Remove all clothing and cover with a towel.
a. Have the client lie down in a cool place. d. Apply cold packs to neck, arm pits, and groin. e. Encourage drinking a sports drink.
A nurse plans care for a client who has a wound that is not healing. Which focused assessments will the nurse complete to develop the patient's plan of care? (Select all that apply.) a. Height b. Allergies c. Alcohol use d. Prealbumin laboratory results e. Liver enzyme laboratory results f. Weight
a. Height c. Alcohol use d. Prealbumin laboratory results e. Liver enzyme laboratory results
An emergency department nurse moves to a new city where heat-related illnesses are common. Which clients does the nurse anticipate being at highest risk for heat-related illnesses? (Select all that apply.) a. Homeless individuals b. People with substance abuse disorders c. Caucasians d. Hockey players e. Older adults f. Obese individuals
a. Homeless individuals b. People with substance abuse disorders e. Older adults f. Obese individuals
An emergency department (ED) nurse is preparing to transfer a client to the trauma intensive care unit. Which information would the nurse include in the nurse-to-nurse hand-off report? (Select all that apply.) a. Mechanism of injury b. Diagnostic test results c. Immunizations d. List of home medications e. Isolation Precautions f. Safety concerns
a. Mechanism of injury b. Diagnostic test results e. Isolation Precautions f. Safety concerns
A hospice nurse plans care for a client who is experiencing pain. Which complementary therapies does the nurse incorporate in this client's pain management plan? (Select all that apply.) a. Play music that the client enjoys. b. Massage tissue that is tender from radiation therapy. c. Rub lavender lotion on the client's feet. d. Ambulate the client in the hall twice a day. e. Administer intravenous morphine. f. Involve the client in guided imagery.
a. Play music that the client enjoys. c. Rub lavender lotion on the client's feet. f. Involve the client in guided imagery.
The complex care provided during an emergency requires interprofessional collaboration. Which team members are paired with the correct responsibilities? (Select all that apply.) a. Psychiatric crisis nurse—interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis b. Forensic nurse examiner—performs rapid assessments to ensure that clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources c. Triage nurse—provides basic life support interventions such as oxygen, basic wound care, splinting, spinal motion restriction, and monitoring of vital signs d. Emergency medical technician—obtains client histories, collects evidence, and offers counseling and follow up care for victims of rape, child abuse, and domestic violence e. Paramedic—provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration
a. Psychiatric crisis nurse—interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis e. Paramedic—provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration
A nurse assesses a client who presents with early koilonychias. Which assessments will the nurse complete next? (Select all that apply.) a. Review the client's health history for a diagnosis of iron deficiency anemia. b. Palpate the client's nail base for potential edemata and sponginess. c. Ask the client about prolonged contact with chemical irritants. d. Assess the client for signs of chronic obstructive pulmonary disease. e. Request a prescription to assess the client's hemoglobin A1C.
a. Review the client's health history for a diagnosis of iron deficiency anemia. e. Request a prescription to assess the client's hemoglobin A1C.
A nurse is providing health education at a community center. Which instructions does the nurse include in teaching about prevention of lightning injuries during a storm? (Select all that apply.) a. Seek shelter inside a building or vehicle. b. Hide under a tall tree. c. Do not take a bath or shower. d. Turn off the television. e. Remove all body piercings. f. Put down golf clubs or gardening tools.
a. Seek shelter inside a building or vehicle. c. Do not take a bath or shower. d. Turn off the television. f. Put down golf clubs or gardening tools.
A hospice nurse is caring for a dying client and family members. Which interventions does the nurse implement? (Select all that apply.) a. Teach family members about physical signs of impending death. b. Encourage the management of adverse symptoms. c. Assist family members by offering an explanation for their loss. d. Encourage reminiscence by both client and family members. e. Avoid spirituality because the client's and the nurse's beliefs may not be congruent. f. Allow the client and family to voice concerns and fears.
a. Teach family members about physical signs of impending death. b. Encourage the management of adverse symptoms. d. Encourage reminiscence by both client and family members. f. Allow the client and family to voice concerns and fears.
The nurse learns that which age-related changes increase the potential for complications of burns? (Select all that apply.) a. Thinner skin b. Slower healing time c. Decreased mobility d. Hyperresponsive immune response e. Increased risk of unnoticed sepsis f. Pre-existing conditions
a. Thinner skin b. Slower healing time c. Decreased mobility e. Increased risk of unnoticed sepsis f. Pre-existing conditions
An emergency department nurse is caring for a trauma patient. Which interventions does the nurse perform during the primary survey? (Select all that apply.) a. Foley catheterization b. Needle decompression c. Initiating IV fluids d. Splinting open fractures e. Endotracheal intubation f. Removing wet clothing g. Laceration repair ANS: B, C, E, F
b. Needle decompression c. Initiating IV fluids e. Endotracheal intubation f. Removing wet clothing
The nurse is teaching participants in a family-oriented community center ways to prevent their older relatives and friends from getting heat-related illnesses. What information does the nurse include? (Select all that apply.) a. Use sunscreen with an SPF of at least 15 when outdoors. b. Take cool baths or showers after outdoor activities. c. Check on the older adult daily in hot weather. d. Drink plenty of liquids throughout the day. e. Wear light-colored, snugly-fitting clothing to wick sweat away.
b. Take cool baths or showers after outdoor activities. c. Check on the older adult daily in hot weather. d. Drink plenty of liquids throughout the day.
A nurse is caring for clients in a busy emergency department. What actions would the nurse take to ensure client and staff safety? (Select all that apply.) a. Leave the stretcher in the lowest position with rails down so that the client can access the bathroom. b. Use two identifiers before each intervention and before mediation administration. c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors. d. Search the belongings of clients with altered mental status to gain essential medical information. e. Use facility policy identification procedures for "Jane/John Doe" clients. f. Check clients for a medical alert bracelets or necklaces. g. Avoid using Security personnel to prevent escalation of client behaviors.
b. Use two identifiers before each intervention and before mediation administration. c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors. d. Search the belongings of clients with altered mental status to gain essential medical information. e. Use facility policy identification procedures for "Jane/John Doe" clients. f. Check clients for a medical alert bracelets or necklaces.
An emergency department nurse is caring for a client who had been hiking in the mountains for the past 2 days. What are the most important indicators that a client is experiencing high-altitude pulmonary edema (HAPE)? (Select all that apply.) a. Ataxia b. Confusion c. Crackles in both lung fields d. Decreased level of consciousness e. Persistent dry cough f. Reports "feeling hung over"
c. Crackles in both lung fields e. Persistent dry cough
A nurse teaches a client's family members about signs and symptoms of approaching death. Which of the following does the nurse include in this teaching? (Select all that apply.) a. Warm and flushed extremities b. Long periods of insomnia c. Increased respiratory rate d. Decreased appetite e. Congestion and gurgling f. Incontinence
d. Decreased appetite e. Congestion and gurgling f. Incontinence
A nurse assesses an older adult's skin. Which findings require immediate referral? (Select all that apply.) a. Excessive moisture under axilla b. Increased hair thinning c. Presence of toenail fungus d. Lesion with various colors e. Spider veins on legs f. Asymmetric 6-mm dark lesion on forehead
d. Lesion with various colors f. Asymmetric 6-mm dark lesion on forehead
A nurse prepares to discharge an older adult client home from the emergency department (ED). What actions does the nurse take to prevent future ED visits? (Select all that apply.) a. Provide medical supplies to the family. b. Consult a home health agency. c. Encourage participation in community activities. d. Screen for depression and suicide. e. Complete a functional assessment.
d. Screen for depression and suicide. e. Complete a functional assessment.
