NR 224- Exam 3

A grieving pt complains of confusion, inability to concentrate, and insomnia. What do these symptoms indicate? 1. these are normal symptoms of grief 2. there is a need for pharmacological support for insomnia 3. the pt is experiencing complicated grief 4. these are common complaints of the admitted pt

1

A hospice nurse sits at the bedside of a male pt in the final stages of cancer. He and his parents made the decision that he would move home and they would help him in the final stages of his disease. The family participates in his care, but lately the nurse has increased the amount of time she spends with the family. Whenever she enters the room or approaches the pt to give care, she touches his shoulder and tells him that she is present. This is an example of what type of touch? 1. caring touch 2. protective touch 3. task-oriented touch 4. interpersonal touch

1

A nurse assess 4 pts. Which pt has the greatest risk for hypomagnesemia? 1. 72 y/o w/ chronic alcoholism 2. 79 y/o w/ bone cancer 3. 41 y/o w/ hypernatremia 4. 46 y/o w/ respiratory acidosis

1

A nurse uses long firm, strokes distal to proximal while bathing a pt's legs because: 1. it promotes venous circulation 2. it covers a larger area of the leg 3. it completes care in a timely fashion 4. it prevents blood clots in legs

1

A year after her husband's death, a widow visits the unit on which he died. She talks about the anniversary and how much she misses him. Which type of grief is she experiencing? 1. normal 2. complicated 3. chronic 4. disenfranchised

1

Nurse is listening to a student provide instruction to a pt who is having difficulty with activities needed to care for soft contact lenses. Which of the following statements by the nursing student might require some correction by the nurse? 1. use tap water to clean soft lenses 2. follow recommendations of lens manufacturer when inserting the lenses 3. keep lenses moist or wet when not worn 4. use fresh solution daily when storing and disinfecting lenses

1

The HCP order is 500 mL 0.9% NaCl IV over 4 hours. Which rate does a nurse program into the infusion pump? 1. 125 mL/hr 2. 167 mL/hr 3. 200 mL/hr 4. 1000 mL/hr

1

A family member of a dying pt talks casually with the nurse and expresses relief that she will not have to visit at the hospital anymore. Which theoretical description of grief best applies to this family member? 1. denial 2. anticipatory greif 3. yearning and searching 4. dysfunctional greif

2

A nurse is planning care for a group of pts who have requested the use of complementary health modalities. Which pt is not a good candidate for guided imagery? 1. pregnant pt 2. hypertensive pt 3. pt with post traumatic stress disorder (PTSD) 4. a pediatric pt

3

A pt receiving chemotherapy experiences stomatitis. The nurse advises the pt to use: 1. community mouthwash 2. alcohol-based mouth rinse 3. normal saline rinses 4. firm toothbrush

3

Several nurses on a busy unit are using relaxation strategies while at work. What is the desired workplace outcome from this intervention? (Select all that apply.) A. Improved health among the staff B. Increased patient safety C. Improved staff satisfaction D. Increased staff retention E. Fewer overtime assignments

3, 4

When you are assigned to a pt who has a reduced LOC and requires mouth care, which physical assessment techniques should you perform before the procedure? (select all that apply) 1. oxygen saturation 2. heart rate 3. respirations 4. gag reflex 5. response to painful stimulus

3, 4

A nurse assess pain and redness at a vascular access device (VAD) site. Which action is taken first? 1. apply a warm, moist compress 2. monitor the pt's BP 3. aspirate the fluid volume from the VAD 4. stop the infusion and discontinue the IV infusion

4

The pt whom you are caring needs a liver transplant to survive. This pt has been out of work for several months and doesn't have health insurance or enough cash. Even though several ethical principles are at work in this case, list the principles from highest to lowest priority: 1. accountability: you as the nurse are accountable for the well-being of this pt 2. respect for autonomy: this pt's autonomy will be violated if he does not receive the liver transplant 3. ethics of care: the caring thing that a nurse could provide this pt is resources for a liver transplant 4. justice: the greatest question in this situation is how to determine the just distribution of resources

4, 2, 3, 1

Ethical dilemmas often arise over a conflict of opinion. Reliance on a predictable series of steps can help people in conflict find common ground. All of the following actions can help resolve conflict. What is the best order of these actions in order to promote the resolution of an ethical dilemma? 1. list the actions that could be taken to resolve the dilemma 2. agree on a statement of the problem or dilemma that you are trying to resolve 3. agree on a plan to evaluate the action over time 4. gather all relevant information regarding the clinical, social, and spiritual aspects of the dilemma 5. take time to clarify values and distinguish between facts and opinions-your own and those of others involved 6. negotiate a plan

4, 5, 2, 1, 6, 3

A patient has 250 mL of a jejunostomy feeding with 30 mL of water before and after feeding and 200 mL of urine. Thirty minutes later the patient has 100 mL of diarrhea. At 1300 the patient receives 150 mL of blood and voids another 200 mL. Calculate the patient's intake. Record your answer as a whole number. _____ mL

460 mL 250 mL of feeding + 60 mL of water (30 mL before and 30 mL after feeding) + 150 mL of blood = 460 mL

Which patient will cause the nurse to question an order for acupuncture? A. pt with AIDS B. pt with osteoarthritis C. pt with low back pain D. pt with migraine headaches

A

A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse include in the plan of care? A. infuse hypotonic IV fluids B. implement a fluid restriction C. increase sodium intake D. administer sodium polystyrene sulfonate

A indicated for the treatment of hypernatremia expand the ECF volume and rehydrate the cells

A nurse is assessing a client as part of an admission history. The client reports drinking an herbal tea every afternoon at work to relieve stress. Tea includes which if the following ingredients? A. chamomile B. ginseng C. ginger D. echinacea

A this produces a calming effect and reduces anxiety

A nurse is providing hygiene care to a bariatric patient using chlorhexidine gluconate (CHG) wipes. Which actions will the nurse take? (Select all that apply.) a. Do not rinse. b. Clean under breasts. c. Inform that the skin will feel sticky. d. Dry thoroughly between skin folds. e. Use two wipes for each area of the body.

A, B, C

Which actions by the nurse should be done in order to get to know the pt? (select all that apply) A. avoid assumptions B. focus on the pt C. engage in a caring relationship D. form the relationship very quickly E. not address spiritual or higher needs

A, B, C

A nurse is describing the therapeutic effects of imagery. Which information should the nurse include in the teaching session? (Select all that apply.) A. controls pain B. decreases nightmares C. improves social anxiety disorders D. helps with irritable bowel syndrome E. reduces relapses in alcohol treatment

A, B, D

A nurse is consoling the partner of a client who just died after a long battle with liver cancer. The grieving partner states, "I hate them for leaving me." Which of the following statements should the nurse make to facilitate mourning for the partner? (select all that apply) A. would you like me to contact the chaplain to come and speak with you? B. you will feel better soon. You have been expecting this for a while now. C. let's talk about your children and how they are going to react D. you know, it's quite normal to feel anger toward your loved one at this time E. tell me more about how you are feeling

A, D, E

A 2-year-old child is brought into the emergency department after ingesting a medication that causes respiratory depression. For which acid-base imbalance will the nurse most closely monitor this child? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic acidosis d. Metabolic alkalosis

B

A child's immunization may cause discomfort during administration, but the benefits of protection from disease, both for the individual and society, outweigh the temporary discomforts. Which principle is involved in this situation? A. Fidelity B. Beneficence C. Nonmaleficence D. Respect for autonomy

B

The nurse is providing oral care to an unconscious patient and notes that the patient has extremely bad breath. Which term will the nurse use when reporting to the oncoming shift? A. cheilitis B. halitosis C. glossitis D. dental caries

B this is the term for bad breath

A nurse is planning care for a client who has dehydration. Which of the following actions should the nurse include? A. administer antihypertensive on schedule B. check the client's weight each morning C. notify the provider of a urine output greater than 30 ml/hr D. encourage independent ambulation four times a day

B include obtaining the client's weight each day at the same time so the nurse can evaluate the client's response to treatment

A nurse receives a lab report for a client indicating a potassium level of 5.2 mEq/L. When notifying the provider, the nurse should expect which of the following actions? A. starting an IV infusion of 0.9% sodium chloride B. consulting w/ dietitian to increase intake of potassium C. initiating continuous cardiac monitoring D. preparing the client for gastric lavage

C need cardiac monitoring b/c K+ deals with heart rhythm

A nurse is about to perform postmortem care of a client. The family wishes to view the body. Which of the following actions should the nurse take? (select all that apply) A. remove the dentures from the body B. make sure the body is lying completely flat C. apply fresh linens and place a clean gown on the body D. remove all equipment from the bedside E. dim the lights in the room

C, D, E

A cancer patient asks the nurse what the criteria are for hospice care. Which information should the nurse share with the patient? a. It is for those needing assistance with pain management. b. It is for those having a terminal illness, such as cancer. c. It is for those with completion of an advance directive. d. It is for those expected to live less than 6 months.

D

A chemotherapy patient has gained 5 pounds in 2 days. Which assessment question by the nurse is most appropriate? a. "Are you following any weight loss program?" b. "How many calories a day do you consume?" c. "Do you have dry mouth or feel thirsty?" d. "How many times a day do you urinate?"

D

A nurse is assessing a patient. Which assessment finding should cause a nurse to further assess for extracellular fluid volume deficit? a. Moist mucous membranes b. Postural hypotension c. Supple skin turgor d. Pitting edema

B

A nurse is caring for a patient whose ECG presents with changes characteristic of hypokalemia. Which assessment finding will the nurse expect? A. dry mucous membranes B. abdominal distention C. distended neck veins D. flushed skin

B

A self-sufficient bedridden patient is unable to reach all body parts. Which type of bath will the nurse assign to the nursing assistive personnel? A. bag bath B. sponge bath C. partial bed bath D. complete bed bath

C

A nurse provides care that is receptive to pts' and families' perceptions of caring. Which action will the nurse take? A. provides clear, accurate information B. just performs nursing tasks competently C. does as much for the pt as possible D. focuses solely on the pt's diagnosis

A

A patient has dehydration. While planning care, the nurse considers that the majority of the patient's total water volume exists in with compartment? A. intracellular B. extracellular C. intravascular D. transcellular

A

A patient has had two family members die during the past 2 days. Which coping strategy is most appropriate for the nurse to suggest to the patient? a. Writing in a journal b. Drinking alcohol to go to sleep c. Exercising vigorously rather than sleeping d. Avoiding talking with friends and family members

A

A patient has scaling of the scalp. Which term will the nurse use to report this finding to the oncoming staff? A. dandruff B. alopecia C. pediculosis D. xerostomia

A

A patient is experiencing respiratory acidosis. Which organ system is responsible for compensation in this patient? A. renal B. endocrine C. respiratory D. gastrointestinal

A

A patient is proficient at meditation from long-time use of the technique. Which finding in the medication history will cause the nurse to follow up? A. takes thyroid-generating medication B. takes corticosteroid medication C. takes loop diuretic medication D. take anticoagulant medication

A

A pt asks the nurse for a nonmedical approach for excessive worry and work stress. Which therapy should the nurse recommend? A. meditation B. acupuncture C. ayurvedic herbs D. chiropractic care

A

When designing a plan for pain management for a post-op pt, the nurse assesses that the pt's priority is to be as free of pain as possible. The nurse continually reviews the plan with the pt to ensure that the pt's priority is met. Which principle is used to encourage the nurse to monitor the pt's response to pain? 1. fidelity 2. beneficence 3. non-maleficence 4. respect for autonomy

1

The debilitated patient is resisting attempts by the nurse to provide oral hygiene. Which action will the nurse take next? A. insert an oral airway B. place the pt in a flat, supine position C. use undiluted hydrogen peroxide as a cleaner D. quickly proceed while not talking to the pt

A

Which of the following statements best explains the actions of therapeutic touch (TT)? 1. intentionally mobilizes energy to balance, harmonize, and repattern the recipient's biofield 2. intentionally heals specific diseases or corrects certain symptoms 3. is overwhelmingly effective in many conditions 4. is completely safe and does not warrant any special precautions

1

The patient is diagnosed with athlete's foot (tinea pedis). The patient says that he is relieved because it is only athlete's foot, and it can be treated easily. Which information should the nurse consider when formulating a response to the patient? A. contagious with frequent recurrences B. helpful to air-dry feet after bathing C. treated with salicylic acid D. caused by lice

A

The patient is reporting an inability to clear nasal passages. Which action will the nurse take? a. Use gentle suction to prevent tissue damage. b. Instruct patient to blow nose forcefully to clear the passage. c. Place a dry washcloth under the nose to absorb secretions. d. Insert a cotton-tipped applicator to the back of the nose.

A

The patient reports to the nurse of being afraid to speak up regarding a desire to end care for fear of upsetting spouse and children. Which principle in the nursing code of ethics ensures that the nurse will promote the patient's cause? a. Advocacy b. Responsibility c. Confidentiality d. Accountability

A

When assessing a patient's feet, the nurse notices that the toenails are thick and separated from the nail bed. What does the nurse most likely suspect is the cause of this condition? A. fungi B. friction C. nail polish D. nail polish remover

A

Which action by the nurse indicates a safe and efficient use of social networks? a. Promotes support for a local health charity b. Posts a picture of a patient's infected foot c. Vents about a patient problem at work d. Friends a patient

A

A severely depressed patient cannot state any positive attributes to life. The nurse patiently sits with this patient and assists the patient to identify several activities the patient is actually looking forward to in life. Which spiritual concept is the nurse trying to promote? a. Time management b. Reminiscence c. Hope d. Faith

C

A therapeutic touch practitioner scans the patient's body. What is the purpose of the practitioner's actions? A. to identify blocked moxibustion B. to identify universal life energy C. to identify energy obstructions D. to identify structural and functional imbalance

C

A teen with an anxiety disorder is referred for biofeedback because the parents do not want their child to take anxiolytics. Which statement from the teen indicates successful learning? A. biofeedback will help me with my thoughts and physiological responses to stress B. biofeedback will direct my energies in an intentional way when stressed C. biofeedback will allow me to manipulate my stressed out joints D. biofeedback will let me assess and redirect my energy fields

A

The nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient with D5W hanging with the blood b. A patient with type A blood receiving type O blood c. A patient with intravenous potassium chloride that is diluted d. A patient with a right mastectomy and an intravenous site in the left arm

A to make sure there is no medication error

Four patients arrive at the emergency department at the same time. Which patient will the nurse see first? a. An infant with temperature of 102.2° F and diarrhea for 3 days b. A teenager with a sprained ankle and excessive edema c. A middle-aged adult with abdominal pain who is moaning and holding her stomach d. An older adult with nausea and vomiting for 3 days with blood pressure 112/60

A

In most ethical dilemmas in health care, the solution to the dilemma requires negotiation among members of the health care team. Why is the nurse's point of view valuable? 1. nurses understand the principle of autonomy to guide respect for a pt's self-worth 2. Nurses have a scope of practice that encourages their presence during ethical decisions 3. Nurses develop a relationship with the pt that is unique among all health care professionals 4. the nurse's code of ethics recommends that a nurse be present at any ethical discussion about pt care

3

To best assist a pt in the grieving process, which of the following is the most helpful to determine? 1. previous experiences with grief and loss 2. religious affiliation and denomination 3. ethnic background and cultural practices 4. current financial status

1

What assessment does the nurse make before hanging IV fluid containing potassium? 1. urine output 2. arterial blood gases 3. fullness of neck veins 4. LOC

1

When a nurse helps a pt find the meaning of cancer by supporting beliefs about life, this is an example of: 1. instilling hope 2. forming a human-altruistic value system 3. cultural caring 4. being with

1

Which of the following properly applies an ethical principle to justify access to health care? (select all that apply) 1. access to health care reflects the commitment of society to principles of beneficence and justice 2. if low-income compromises access to care, respect for autonomy is compromised 3. access to healthcare is a privilege in the US, not a right 4. poor access to affordable healthcare causes harm that is ethically troubling because non-maleficence is a basic principle of health care ethics 5. providers are exempt from fidelity to people with drug addiction because addiction reflects a lack of personal accountability 6. if a new drug is discovered that cures a disease, but at great per pt, the principle of justice suggests that the drug should be made available to those who can afford it

1, 2, 4

When planning care for the dying pt, which interventions promote the pt's dignity? (select all that apply) 1. providing respect 2. viewing pts as a whole 3. providing symptom management 4. showing interest 5. being present 6. using a preferred name

1, 2, 4, 5, 6

The Ethics of care suggests that ethical dilemmas can be best solved by attention to relationships. How does this differ from other ethical practices? (Select all that apply) 1. ethics of care pays attention to the environment in which caring occurs 2.ethics of care pays attention to the stories of the people involved in the ethical issue 3. ethics of care is used only in nursing practice 4. ethics of care focuses only on the code of ethics for nurses 5. ethics of care focuses only on understanding relationships

1, 2, 5

A pt has severe hypercalcemia. What are the priority nursing interventions? (Select all that apply) 1. fall prevention interventions 2. teaching regarding sodium restriction 3. encouraging increased fluid intake 4. explaining how to take daily weights

1, 3, 4

The American Dental Association suggests that pts who are at risk for poor hygiene use the following interventions for oral care: (select all that apply) 1. use antimicrobial toothpaste 2. brush teeth 4 times a day 3. use 0.12% chlorhexidine gluconate (CHG) oral rinses 4. use a soft toothbrush for oral care 5. avoid cleaning the gums and tongue

1, 3, 4

Which factors influence a person's approach to death? (Select all that apply) 1. culture 2. age 3. spirituality 4. personal beliefs 5. previous experiences with death 6. gender 7. level of education 8. degree of social support

1, 3, 4, 5, 8

What are the physical changes that occur as death approaches? (select all that apply) 1. unresponsiveness 2. erythema 3. mottling 4. restlessness 5. increased urine output 6. weakness 7. incontinence

1, 3, 4, 6, 7

88 y/o pt comes to the clinic and has lost 10 lbs in 6 weeks without being on a special diet. The pt tells the nurse that he has trouble chewing his food. Which of the following factors are normal aging changes that can affect an older adult's oral health? (select all that apply) 1. dentures do not always fit properly 2. most older adults have an increase in saliva secretions 3. with aging the periodontal membrane becomes tighter and painful 4. many older adults are edentulous, and remaining teeth are often decayed 5. the teeth of elderly pts are more sensitive to hot and cold

1, 4

A pt has hypokalemia with stable cardiac function. What are the priority nursing interventions? (Select all that apply) 1. fall prevention interventions 2. teaching regarding sodium restriction 3. encouraging increased fluid intake 4. monitoring for constipation 5. explaining how to take daily weights

1, 4

A nurse demonstrated caring by helping family members to: (Select all that apply) 1. become active participants in care 2. remove themselves from personal care 3. make health care decisions for the pt 4. have uninterrupted time for family and pt to be together 5. have opportunities for the family to discuss their concerns

1, 4, 5

Of the 5 caring processes described by Swanson, which describes "knowing the pt"? 1. anticipating the pt's cultural preferences 2. determining the pt's physician preference 3. establishing an understanding of a specific pt 4. gathering task-oriented information during assessment

3

Four patients in labor all request epidural analgesia to manage their pain at the same time. Which ethical principle is most compromised when only one nurse anesthetist is on call? a. Justice b. Fidelity c. Beneficence d. Nonmaleficence

A

In making rounds, the nurse meets a patient for the first time. The nurse asks the patient when morning medications are taken, such as before breakfast, after breakfast, or during breakfast. What does knowing the patient allow the nurse to do? A. choose the most appropriate time to give the medication B. know what information to put on the medication error report form C. explain to the pt that the medication will not be given at the usual time D. evaluate whether or not the pt is taking the medication correctly at home

A

A muslim woman enters the clinic to have a women's health examination for the 1st time. Which nursing behavior applies Swanson's caring process of "knowing the pt"? 1. share feelings about the importance of having regular women's health examinations 2. gaining an understanding of what a woman's health examination means to the pt 3. recognizing that the pt is modest; and obtaining gender congruent caregiver 4. explain the risk factors for cervical cancer

2

In addition to an adequate pt assessment, when a nurse uses one of the nursing-accessible complementary therapies, he or she must ensure that which of the following has occurred? 1. the family has provided permission 2. the pt has provided permission and consent 3. the HCP has given approval or provided order for the therapy 4. he or she has documented that the pt has a complete understanding of complementary and alternative medicine

2

The application of utilitarianism does not always resolve an ethical dilemma. Which of the following statements best explains why? 1. utilitarianism refers to usefulness and therefore eliminates the need to talk about spiritual values 2. in a diverse community it can be difficult to find agreement on a definition of usefulness, the focus of utilitarianism 3. even when agreement about a definition of usefulness exists in a community, laws prohibit an application of utilitarianism 4. difficult ethical decisions cannot be resolved by talking about the usefulness of a procedure

2

The nurse delegates needed hygiene care for an elderly stroke pt. Which intervention would be appropriate for the nursing assistive personnel to accomplish during the bath? 1. checking distal pulses 2. providing ROM exercises to extremities 3. determining type of treatment for stage I pressure ulcer 4. changing the dressing over an intravenous site

2

Traditional Chinese Medicine (TCM) is used by many pts. Which statement most accurately describes intervention(s) offered by TCM providers? 1. uses acupuncture as its primary intervention modality 2. uses many modalities based on the individual's needs 3. uses primarily herbal remedies and exercise 4. is the equivalent of medical acupuncture

2

What role do pts have in complementary and alternative therapies? 1. submissive to the practitioner 2. actively involved in the treatment 3. allow practitioner to experiment 4. total believer in what is being taught

2

When providing postmortem care, which action is a priority for the nurse? 1. locating the pt's clothing 2. providing culturally and religiously sensitive care in body preparation 3. transporting the body to the morgue as soon as possible 4. providing postmortem care to protect the family of the deceased from having to view the body

2

Which of the following is the best invention to help a hospitalized pt maintain some autonomy? 1. use therapeutic techniques when communicating with the pt 2. allow the pt to determine timing and scheduling of interventions 3. encourage family to only visit for short periods of time 4. provide the pt with a private room close to the nurse's station

2

Which pts does a nurse plan to teach regarding water restriction? 1. 23 y/o w/ extracellular fluid volume ECF deficit 2. 34 y/o w/ hyponatremia 3. 47 y/o w/ hypercalcemia 4. 60 y/o w/ metaboloc acidosis

2

What is the proper position to use for an unresponsive pt during oral care to prevent aspiration? (select all that apply) 1. prone position 2. sim's position 3. semi-fowler's position with head to side 4. trendelenburg position 5. supine position

2, 3

Resolution of an ethical dilemma involves discussion with the patient, the patient's family, and participants from all health care disciplines. Which of the following describes the role of the nurse in the resolution of ethical dilemmas? A. To articulate his or her unique point of view, including knowledge based on clinical and psychosocial observations B. To await new clinical orders from the physician C. To limit discussions about ethical principals D. To allow the patient and the physician to resolve the dilemma without regard to personally held values or opinions regarding the ethical issues

A

It can be difficult to agree on a common definition of the word quality when it comes to quality of life. Why? (select all that apply) 1. average income varies in different regions of the country 2. community values influence definitions of quality, and they are subject to change over time 3. individual experiences influence perceptions of quality in different ways, making consensus difficult 4. the value of elements such as cognitive skills, ability to perform meaningful work, and relationship to family is difficult to quantify using objective measures. 5. statistical analysis is difficult to apply when the outcome cannot be quantified 6. whether or not a person has a job is an objective measure, but it does not play a role in understanding quality of life

2, 3, 4, 5

A nurse is caring for a pt experiencing a stress response. The nurse plans care with the knowledge that systems respond to stress in what manner? (select all that apply) 1. always fail and cause illness and disease 2. cause negative responses over time 3. react the same way for all individuals 4. protect an individual from harm in the short term

2, 4

A pt is receiving palliative care for symptom management r/t anxiety and pain. A family member asks if the pt is dying and now in "hospice." What does the nurse tell the family member about palliative care? (select all that apply) 1. palliative care and hospice are the same thing 2. palliative care is for any pt, any time, any disease, in any setting 3. palliative care strategies are primarily designed to treat the pt's illness 4. palliative care relieves the symptoms of illness and treatment 5. palliative care selects home health care services

2, 4

What are the correct steps to resolve an ethical dilemma on a clinical unit? Place the steps in correct order. 1. clarify values 2. ask the question, is this an ethical dilemma 3. verbalize the problem 4. gather information 5. identify course of action 6. evaluate the plan 7. negotiate a plan

2, 4, 1, 3, 5, 7, 6

The student nurse is teaching a family member the importance of foot care for his or her mother, who has diabetes. Which safety precautions are important for the family member to know to prevent infection? (Select all that apply) 1. cut nails frequently 2. asses skin for redness, abrasions, and open areas daily 3. soak feet in water at least 10 mins before nail care 4. apply lotion to feet daily 5. clean b/t toes after bathing

2, 4, 5

A pt with a malignant brain tumor requires oral care. The pt's LOC has declined, with the pt only being able to respond to voice commands. Place the following steps in the correct order for administration of oral care. 1. if the pt is uncooperative or having difficulty keeping mouth open, insert an oral airway 2. raise bed, lower side rail, and position pt close to side of bed with head of bed raised up to 30 degrees 3. using a brush moistened with chlorhexidine paste, clean chewing and inner tooth surfaces first 4. for patients without teeth, use a toothette moistened in chlorhexidine rinse to clean oral cavity 5. remove partial plate or dentures if present 6. gently brush tongue but avoid stimulating gag reflex

2, 5, 1, 3, 6, 4

A nurse is caring for a diabetic patient with a bowel obstruction and has orders to ensure that the volume of intake matches the output. In the past 4 hours, the patient received dextrose 5% with 0.9% sodium chloride through a 22-gauge catheter infusing at 150 mL/hr and has eaten 200 mL of ice chips. The patient also has an NG suction tube set to low continuous suction that had 300 mL output. The patient has voided 400 mL of urine. After reporting these values to the health care provider, which order does the nurse anticipate? a. Add a potassium supplement to replace loss from output. b. Decrease the rate of intravenous fluids to 100 mL/hr. c. Administer a diuretic to prevent fluid volume excess. d. Discontinue the nasogastric suctioning.

A

A nurse is caring for an older adult who needs to enter an assisted living facility following discharge from the hospital. Which of the following is an example of listening that displays caring? 1. the nurse encourages the pt to talk about his concerns while reviewing the computer screen in the room 2. the nurse sits at the pt's bedside, listens as he relays his fear of never seeing his home again, and then asks if he wants anything to eat 3. the nurse listens to the pt's story while sitting on the side of the bed and then summarizes the story 4. the nurse listens to the pt talk about his fears of not returning home and then tells him to think positively

3

A pt is admitted to the hospital with severe dyspnea and wheezing. Arterial blood gas levels on admission are pH- 7.26; PaCO2- 55 mm Hg; PaO2- 68 mm Hg; HCO-3 - 24. The nurse interprets these laboratory values to indicate: 1. metabolic acidosis 2. metabolic alkalosis 3. respiratory acidosis 4. respiratory alkalosis

3

A young mother is dying of breast cancer with bone metastasis and tells the nurse, "my body hurts so much. I can hardly move. Why is God making me suffer when I have done nothing bad in my life? I feel like giving up. How can I care for my children when I can't even care for myself?" What is the most appropriate nursing diagnosis foe this pt? 1. spiritual distress r/t questioning God 2. hopelessness r/t terminal diagnosis 3. pain r/t disease process 4. anticipatory grief r/t impending death

3

An older adult pt is receiving IV 0.9% NaCl. A nurse detects new onset of crackles in the lung bases. What is the priority action? 1. Notify HCP 2. record in medical record 3. decrease IV flow rate 4. discontinue the IV site

3

The ANA code of nursing ethics articulates that the nurse "promotes, advocates for, and strives to protect the health, safety and rights of the pt." This includes the protection of pt privacy. On the basis of this principle, if you participate in a public online social network, could you post images of a pt's x-ray film if you obscured or deleted all pt identifiers? 1. yes, because pt privacy would not be violated since pt identifiers were removed 2. yes, because respect for autonomy implies that you have the autonomy to decide what constitutes privacy 3. no because even though pt identifiers are removed, someone could identify the pt on the basis of other comments that you make online about his or her condition and your place of work 4. no because the principle of justice requires you to allocate resources fairly

3

The nurse observes an adult Middle Eastern pt attempting to bathe himself with only his left hand. The nurse recognizes that this behavior likely r/t: 1. obsessive compulsive disorder 2. personal preferences 3. the pt's cultural norm 4. controlling behaviors

3

What is the palliative care team's primary obligation for pt with severe pain? 1. providing postmortem care 2. teaching about grief stages 3. enhancing pt's quality of life 4. supporting the family after the death

3

When delegating I&O measurement to nursing assistive personnel, a nurse instructs them to record what information for ice chips? 1. the total volume 2. two-thirds of the volume 3. one-half of the volume 4. one-quarter of the volume

3

Which assessment does a nurse use as a clinical marker if vascular volume in a pt at high risk of extracellular fluid volume (ECV) deficit? 1. dryness of mucous membranes 2. presences or absence of edema 3. fullness of neck veins when supine 4. fullness of neck veins when upright

3

Which comment to a pt by a new nurse regarding palliative care needs to be corrected? 1. even though you're continuing treatment, palliative care is something we might want to talk about 2. palliative care is appropriate for people with any diagnosis 3. only people who are dying receive palliative care 4. children are able to receive palliative care

3

Which statement best describes the evidence associated with complementary therapies as a whole? 1. many clinical trials in complementary therapies support their effectiveness in a wide range of clinical problems 2. it is difficult to find funding for studies about complementary therapies. Therefore we should not expect to find evidence supporting its use 3. the science supporting the effectiveness of complementary therapies is early in its development 4. most of the research examining complementary and alternative therapies has found little clinical evidence, suggesting that, although people like them, they are not effective

3

While planning care for a pt, a nurse understands that providing integrative care includes treating which of the following? 1. disease, spirit, and family interactions 2. desires and emotions of the pt 3. mind-body-spirit of pts and their families 4. muscles, nerves, and spine disorders

3

While planning morning care, which of the following pts would have the highest priority to receive his or her bath first? 1. a pt who just returned to the nursing unit from a diagnostic test 2. a pt who prefers a bath in the evening when his wife visits and can help him 3. a pt who is experiencing frequent incontinent diarrheal stools and urine 4. a pt who has been awake all night because of pain 8/10

3

Integrity of the oral mucosa depends on salivary secretion. Which of the following factors impairs salivary secretion? (select all that apply) 1. use of cough drops 2. immunosuppression 3. radiation therapy 4. dehydration 5. presence of oral airway

3, 4

Which complementary therapies are most easily learned and applied by a nurse? (Select all that apply) 1. massage therapy 2. traditional Chinese medicine 3. progressive relaxation 4. breathwork and guided imagery 5. therapeutic touch

3, 4

Which of the following is a strategy for creating work environments that enable nurses to demonstrate more caring behaviors? (select all that apply) 1. decreasing the number of consecutive shifts of the nursing staff 2. increasing salary and vacation benefits of the nursing staff 3. increasing the number of nurses who work each shift to decrease the nurse-pt ratio 4. encouraging increased input concerning nursing functions from health care providers 5. providing nursing staff an opportunity to discuss practice changes they can implement to enhance opportunities for pt caring

3, 5

A nurse is caring for a dying patient. When is the best time for the nurse to discuss end-of life care? a. During assessment b. During planning c. During implementation d. During evaluation

A

A nurse is caring for a patient with peripheral intravenous (IV) therapy. Which task will the nurse assign to the nursing assistive personnel? A. recording intake and output B. regulating IV flow rate C. starting peripheral IV therapy D. changing a peripheral IV dressing

A

A nurse hears a colleague tell a nursing student that she never touches a pt unless she is preforming a procedure or doing an assessment. The nurse tells the student that from a caring perspective: 1. She does not touch the pts either 2. Touch is a type of verbal communication 3. Touch is only used when a pt is in pain 4. Touch forms a connection b/t nurse and pt

4

A nurse is assigned to care for the following pts. Which of the pts is most risk for developing skin problems and thus requiring through bathing and skin care? 1. a 44 y/o female who has had removal of a breast lesion and is having her menstrual period 2. a 56 y/o male pt who is homeless and admitted to the emergency department with malnutrition and dehydration and who has an intravenous line 3. a 60 y/o female who experienced a stroke with R sided paralysis and has an orthopedic brace applied to the L leg 4. a 70 y/o pt who has diabetes and dementia and has been incontinent of stool

4

A nursing professor is teaching a nursing student about caring pts who use herbal preparations in addition to prescribed medications. Which of the following statements made by the student indicates that the student understands herbal preparations? 1. herbal preparations are regulated by the FDA; therefore I need to tell pts that they are completely safe 2. They are natural products and therefore are safe as long as you use them for the conditions that are indicated 3. these preparations are covered by insurance, including Medicare, Medicaid and private prayers 4. we need to treat herbal preparations as though they are "drugs" because many have active ingredients that can interact with other medications and change physiological responses

4

A pt is admitted to a medical unit. The pt is fearful of hospitals. The nurse carefully assesses the pt to determine the exact fears and then establishes interventions designed to reduce these fears. In this setting how is the nurse practicing pt advocacy? 1. seeking out the nursing supervisor to talk with the pt 2. documenting pt fears in the medical record in a timely manner 3. working to change the hospital environment 4. assessing the pt's point of view and preparing to articulate it

4

A pt is fearful of upcoming surgery and a possible cancer diagnosis. He discusses his love for the Bible with his nurse, who recommends a favorite Bible verse. Another nurse tells the pt's nurse that there is no place in nursing for spiritual caring. The pt's nurse replies: 1. you're correct spiritual care should be left to a pastoral care professional 2. you're correct; religion is a personal decision 3. nurses should explain their own religious beliefs to pts 4. spiritual, mind, and body connections can affect health

4

A pt is hyperventilating from acute pain and hypoxia. Interventions to manage his pain and oxygenation will decrease his risk of which acid-base imbalance? 1. metabolic acidosis 2. metabolic alkalosis 3. respiratory acidosis 4. respiratory alkalosis

4

A pt who has been using relaxation wants a better response. The nurse recommends the addition of biofeedback. What is the expected outcome r/t using this additional modality? 1. to eat less food 2. to control diabetes 3. to live longer with acquired immunodeficiency syndrome (AIDS) 4. to learn how to control some automatic nervous system responses

4

An example of a nursing behavior that families of acutely ill pts perceive as important to pt's well-being is: 1. making health care decisions for pts 2. having family members provide a pt's total personal hygiene 3. injecting the nurse's perceptions about the level of care provided 4. asking permission before performing a procedure on a pt

4

When a nurse delegates hygiene care for a male patient to a nursing assistive personnel, the NAP must use an electric razor to shave the patient with the following diagnosis: 1. Congestive heart failure 2. Pneumonia 3. Arthritis 4. Thrombocytopenia

4

When planning pt education, it is important to remember that pt's with which of the following illnesses often find relief in complementary therapies? 1. lupus and diabetes 2. ulcers and hepatitis 3. heart disease and pancreatitis 4. chronic back pain and arthritis

4

Which assessment does a nurse interpret as a transfusion reaction? 1. crackles in dependent lobes of lungs 2. high fever, severe hypotension 3. anxiety, itching, confusion 4. chills, tachycardia, and flushing

4

medications may compound the effects of which of these medications? 1. presidone and antibiotics 2. insulin and vitamins 3. cough syrups and aspirin 4. antihypertensive and thyroid-regulating medications

4

A nurse is caring for a pt in pain. Which nursing approach is priority? A. relationship-centered B. technology-centered C. high tech-centered D. family-centered

A

A nurse is providing oral care to a patient with stomatitis. Which technique will the nurse use? A. avoid commercial mouthwashes B. avoid normal saline rinses C. brush with a hard toothbrush D. brush with an alcohol-based toothpaste

A

A nurse is providing pain medication to pts after surgery. Which component is key for the nurse's personal philosophy of nursing? A. caring B. technology C. informatics D. therapeutics

A

Place the following steps for discontinuing IV access in the correct order: 1. perform hand hygiene + apply gloves 2. explain procedure to pt 3. removes IV site dressing and tape 4. Use two identifiers to ensure the correct pt ' 5. stop the infusion and clamp the tubing 6. carefully check the HCP order 7. clean site, withdraw the catheter, and apply pressure

6, 4, 2, 1, 5, 3, 7

A nurse has the responsibility of managing a deceased patient's post-mortem care. Arrange the steps for post-mortem care in the proper order. 1. Bathe the body of the deceased. 2. Collect any needed specimens. 3. Remove all tubes and indwelling lines. 4. Position the body for family visit/viewing. 5. Speak to the family members about their possible participation. 6. Confirm that request for organ/tissue donation and/or autopsy has been made. 7. Notify a support person (e.g., spiritual care provider, bereavement specialist) for the family. 8. Accurately tag the body, indicating the identity of the deceased and safety issues regarding infection control. 9. Elevate the head of the bed.

6, 9, 2, 5, 7, 3, 1, 4, 8

A Native American patient is asking for a spiritual healer. Which person should the nurse try to contact for the patient? A. shaman B. vitalist C. ayurvedic D. curanderismo

A

A nurse attends a seminar on nursing theories for caring. Which information from the nurse indicates a correct understanding of these theories? A. Benner identifies caring as highly connected involving pt and nurse B. Swanson develops 4 caring processes to convey caring in culture C. Watson's transcultural caring views inclusion of culture as caring D. Leininger's theory places care before cure and is transformative

A

A nurse encounters a family who experienced the death of their adult child last year. The parents are talking about the upcoming anniversary of their child's death. The nurse spends time with them discussing their child's life and death. Which nursing principle does the nurse's action best demonstrate? a. Facilitation of normal mourning b. Pain-management technique c. Grief evaluation d. Palliative care

A

A nurse follows the "ethics of care" when working with pts. Which action will the nurse take? A. become the pt's advocate based on the pt's wishes B. makes decisions for the pt solely using analytical principles C. uses only intellectual principles to determine what is best for the pt D. ignores unequal family relationships since that is a personal matter for the family

A

A nurse is assessing a patient who is receiving a blood transfusion and finds that the patient is anxiously fidgeting in bed. The patient is afebrile and dyspneic. The nurse auscultates crackles in both lung bases and sees jugular vein distention. On which transfusion complication will the nurse focus interventions? a. Fluid volume overload b. Hemolytic reaction c. Anaphylactic shock d. Septicemia

A

A nurse is providing postmortem care. Which action will the nurse take? a. Leave dentures in the mouth. b. Lower the head of the bed. c. Cover the body with a sterile sheet. d. Remove all tubes for an autopsy.

A

A nurse is teaching a patient about meridians. Which technique is the nurse preparing the patient to receive? A. acupuncture B. naturopathic C. Latin American traditional healing D. Native American traditional healing

A

The group leader is overheard saying to the gathering of patients, "Focus on your breathing once again .... Notice how it is regular .... Now focus on your left arm .... Notice how relaxed your left arm feels .... Notice the relaxation going down the left arm to the hand." A patient asks the nurse what the group is doing. What is the nurse's best response? A. it is progressive relaxation training B. it is group biofeedback C. it is guided imagery D. it is meditation

A

The health care provider has ordered a hypotonic intravenous (IV) solution to be administered. Which IV bag will the nurse prepare? a. 0.45% sodium chloride (1/2 NS) b. 0.9% sodium chloride (NS) c. Lactated Ringer's (LR) d. Dextrose 5% in Lactated Ringer's (D5LR)

A

The mother of a child who died recently keeps the child's room intact. Family members are encouraging her to redecorate and move forward in life. Which type of grief will the home health nurse recognize the mother is experiencing? a. Normal b. End-of-life c. Abnormal d. Complicated

A

The nurse administers an intravenous (IV) hypertonic solution to a patient. In which direction will the fluid shift? A. from intracellular to extracellular B. from extracellular to intracellular C. from intravascular to intracellular D. from intravascular to interstitial

A

The nurse finds it difficult to care for a patient whose advance directive states that no extraordinary resuscitation measures should be taken. Which step may help the nurse to find resolution in this assignment? a. Scrutinize personal values. b. Call for an ethical committee consult. c. Decline the assignment on religious grounds. d. Convince the family to challenge the directive.

A

The nurse is bathing a patient and notices movement in the patient's hair. Which action will the nurse take? A. use gloves to inspect the hair B. apply a lindane-based shampoo immediately C. shave the hair off of the pt's head D. ignore the movement and continue

A

The nurse is calculating intake and output on a patient. The patient drinks 150 mL of orange juice at breakfast, voids 125 mL after breakfast, vomits 250 mL of greenish fluid, sucks on 60 mL of ice chips, and for lunch consumes 75 mL of chicken broth. Which totals for intake and output will the nurse document in the patient's medical record? a. Intake 255; output 375 b. Intake 285; output 375 c. Intake 505; output 125 d. Intake 535; output 125

A

The nurse is caring for a diabetic patient in renal failure who is in metabolic acidosis. Which laboratory findings are consistent with metabolic acidosis? a. pH 7.3, PaCO2 36 mm Hg, HCO3- 19 mEq/L b. pH 7.5, PaCO2 35 mm Hg, HCO3- 35 mEq/L c. pH 7.32, PaCO2 47 mm Hg, HCO3- 23 mEq/L d. pH 7.35, PaCO2 40 mm Hg, HCO3- 25 mEq/L

A

The nurse is caring for a patient who has diabetes mellitus and circulatory insufficiency, with peripheral neuropathy and urinary incontinence. On which areas does the nurse focus care? A. decreased pain sensation and increased risk of skin impairment B. decreased caloric intake and accelerated wound healing C. high risk for skin infection and low saliva pH level D. high risk for impaired venous return and dementia

A

The nurse is caring for a patient who has multiple ticks on lower legs and body. What should the nurse do to rid the patient of ticks? A. use blunt tweezers and pull upward with steady pressure B. burn the ticks with a match or small lighter C. allow the ticks to drop off by themselves D. apply miconazole and cover with plastic

A

The nurse is caring for a patient who has undergone surgery for a broken leg and has a cast in place. What should the nurse do to prevent skin impairment? A. assess surfaces exposed to the edges of the cast for pressure areas B. keep the pt's blood pressure low to prevent over-perfusion of tissue C. do not allow turning in bed because that may lead to redislocation of the leg D. restrict the pt's dietary intake to reduce the number of times on the bedpan

A

The nurse is caring for a patient who refuses to bathe in the morning. When asked why, the patient says "I always bathe in the evening." Which action by the nurse is best? A. defer the bath until evening and pass on the information to the next shift B. tell the pt that daily morning baths are the "normal" routine C. explain the importance of maintaining morning hygiene practices D. cancel hygiene for the day and attempt again in the morning

A

The nurse is caring for an older-adult patient with Alzheimer's disease who is ambulatory but requires total assistance with activities of daily living (ADLs). The nurse notices that the patient is edentulous. Which area should the nurse assess? A. assess oral cavity B. assess room for drafts C. assess ankles for edema D. assess for reduced sensations

A

The nurse is reviewing laboratory results. Which cation will the nurse observe is the most abundant in the blood? A. sodium B. chloride C. potassium D. magnesium

A

The nurse is teaching about the process of passively moving water from an area of lower particle concentration to an area of higher particle concentration. Which process is the nurse describing? A. osmosis B. filtration C. diffusion D. active transport

A

The patient has an intravenous (IV) line and the nurse needs to remove the gown. In which order will the nurse perform the steps, starting with the first one? 1. Remove the sleeve of the gown from the arm without the IV. 2. Remove the sleeve of the gown from the arm with the IV. 3. Remove the IV solution container from its stand. 4. Pass the IV bag and tubing through the sleeve. A. 1, 2, 3, 4 B. 2, 3, 4, 1 C. 3, 4, 1, 2 D. 4, 1, 2, 3

A

The patient has been brought to the emergency department following a motor vehicle accident. The patient is unresponsive. The driver's license states that glasses are needed to operate a motor vehicle, but no glasses were brought in with the patient. Which action should the nurse take next? A. stand to the side of the pt's eye and observe the cornea B. conclude that the glasses were lost during the accident C. notify the ambulance personnel for missing glasses D. ask the pt where the glasses are

A

The patient is about to undergo a certain procedure and has voiced concern about outcomes and prognosis. The nurse caring for the patient underwent a similar procedure and stops to listen. Which response by the nurse may be most beneficial? A. I had a similar procedure and I can tell you what I went through B. I think you'll be alright, but of course there are no sure guarantees C. I don't think you have anything to worry about. They do lots of these D. I can call the dr and cancel the procedure, if you are really concerned

A

A nurse is reviewing the medical record of a client who has hypocalcemia. The nurse should identify which of the following findings as a risk factor for the development of this electrolyte imbalance? A. Crohn's disease B. post -op following appendectomy C. history of bone cancer D. hyperthyroidism

A client with crohn's disease is at risk for hypocalcemia due to inadequate calcium absorption

A nurse is on a med surg unit caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia? A. client who has a nasogastric suctioning B. client who has chronic constipation C. client who has syndrome of inappropriate antidiuretic hormone D. client who took a toxic dose of sodium bicarbonate antacids

A from the Ng tube and excessive GI loses

A nurse is beginning a complete bed bath for a client. After removing the client's gown and placing a bath blanket over the body, which of the following areas should the nurse wash first? A. face B. feet C. chest D. arms

A greatest risk to the client is the transmission of pathogens from one area of the body to another--> begin with the cleanest area and then move to the dirtiest

A nurse is planning care for a client who develops dyspnea and feels tired after completing morning care. Which of the following actions should the nurse include in the client's plan of care? A. schedule rest periods during morning care B. discontinue morning care for 2 days C. perform all care as quickly as possible D. ask a family member to come in and bathe the client

A planning for rest periods during morning care will help prevent fatigue and continue to foster independence

A nurse is caring for a client scheduled for abdominal surgery. The client reports being worried. Which of the following actions should the nurse take? A. offer information on a relaxation technique and ask the client if they are interested in trying it. B. request a social worker see the client to discuss meditation C. attempt to use biofeedback techniques with the client D. tell the client many people feel the same way before surgery

A recommend a noninvasive technique to facilitate coping

A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? A. Turn the client's head to the side B. Place two fingers in the client's mouth to open it C. Brush the client's teeth once per day D. Inject a mouth rinse into the center of the client's mouth

A this reduces risk of aspiration

A nurse is teaching a group of newly licensed nurses on complementary and alternative therapies they can incorporate into their practice without the need for specialized licensing or certification. Which of the following should the nurse encourage them to use? (select all that apply) A. guided imagery B. massage therapy C. meditation D. music therapy E. therapeutic touch

A, C, D nurses can use guided imagery, meditation and music therapy with clients

A nurse cares for pts. Which areas does caring influence? (select all that apply) A. the way in which pts feel B. the way in which pts learn C. the way in which pts think D. the way in which pts study E. the way in which pts behave

A, C, E

Which of the following actions by the nurse indicate compassion and caring to pts? (select all that apply) A. saying, "I am here" B. including the family in care C. staying with the pt during a bedside test D. relying on monitors and technology E. refining work processes on the unit

A, B, C

The nurse manager of a community clinic arranges for staff in-services about various complementary therapies available in the community. What is the purpose of this training? (Select all that apply.) A. Nurses have a long history of providing some of these therapies and need to be knowledgeable about their positive outcomes. B. Nurses are often asked for recommendations and strategies that promote well-being and quality of life. C. Nurses play an essential role in patient education to provide information about the safe use of these healing strategies. D. Nurses appreciate the cultural aspects of care and recognize that many of these complementary strategies are part of a patient's life. E. Nurses play an essential role in the safe use of complementary therapies. F. Nurses learn how to provide all of the complementary modalities during their basic education.

A, B, C, D, E

An IV fluid is infusing more slowly than ordered. The infusion pump is set correctly. Which factors could cause this slowing? (SELECT ALL) a. Infiltration at vascular access device site b. Patient lying on tubing c. Roller clamp wide open d. Tubing kinked in bedrails e. Circulatory overload

A, B, D

The nurse is caring for a patient who has peripheral neuropathy. Which clinical manifestations does the nurse expect to find upon assessment? (Select all that apply.) A. abnormal gait B. foot deformities C. absent or decreased pedal pulses D. muscle wasting of lower extremities E. decreased hair growth on legs and feet

A, B, D

Which patients will the nurse determine are in need of perineal care? (Select all that apply.) a. A patient with rectal and genital surgical dressings b. A patient with urinary and fecal incontinence c. A circumcised male who is ambulatory d. A patient who has an indwelling catheter e. A bariatric patient

A, B, D, E

A nurse is a member of the ethics committee. Which purposes will the nurse fulfill in this committee? (Select all that apply.) a. Education b. Case consultation c. Purchasing power d. Direct patient care e. Policy recommendation

A, B, E

A nurse is instructing a client who has DM about foot care. Which of the following guidelines should the nurse include? (Select all that apply) A. Inspect the feet daily B. Use moisturizing lotion on the feet C. wash the feet with warm water and let them air dry D. use OTC products to treat abrasions E. wear cotton socks

A, B, E Feet should be inspected daily esp for diabetics Use lotion for smooth and supple skin but do not use b/t toes Pt should wear clean cotton socks each day esp diabetics

A nurse is reviewing the lab test results for a client who has an elevated temperature. The nurse should identify which of the following findings as a manifestation of dehydration?(select all that apply) A. Hct 55% B. blood osmolarity 260 mOsm/kg C. blood sodium 150 mEq/L D. urine specific gravity 1.035 E. blood creatinine 0.6 mg/dL

A, C, D Hct is greater than expected reference range and is an indication of dehydration due to hemoconcentration, blood sodium level is greater than expected and so is urine specific gravity

A nurse is reviewing complementary and alternative therapies with a group of newly licensed nurses. Which of the following interventions are mind-body therapies? (Select all that apply) A. art therapy B. acupressure C. yoga D. therapeutic touch E. biofeedback

A, C, E art therapy allows the client to express unconscious emotions, yoga focuses on achieving well-being through exercise, posture, breathing and meditation, biofeedback increases mental awareness of the body's response to stress

A nurse is selecting a site to insert an intravenous (IV) catheter on an adult. Which actions will the nurse take (Select all that apply.) a. Check for contraindications to the extremity. b. Start proximally and move distally on the arm. c. Choose a vein with minimal curvature. d. Choose the patient's dominant arm. e. Select a vein that is rigid. f. Avoid areas of flexion.

A, C, F

Which assessments will alert the nurse that a patient's IV has infiltrated? (Select all that apply.) a. Edema of the extremity near the insertion site b. Reddish streak proximal to the insertion site c. Skin discolored or pale in appearance d. Pain and warmth at the insertion site e. Palpable venous cord f. Skin cool to the touch

A, C, F

After performing foot care, the nurse checks the medical record and discovers that the patient has a foot disorder caused by a virus. Which condition did the nurse most likely observe? A. corns B. a callus C. plantar warts D. athlete's foot

C

A nurse is administering a diuretic to a patient and teaching the patient about foods to increase. Which food choices by the patient will best indicate successful teaching? a. Milk and cheese b. Potatoes and fresh fruit c. Canned soups and vegetables d. Whole grains and dark green leafy vegetables

B

A nurse is assessing a patient's skin. Which patient is most at risk for impaired skin integrity? A. pt who is afebrile B. pt who is diaphoretic C. pt with strong pedal pulses D. pt with adequate skin turgor

B

A nurse is discussing the plan of care for a client who reports the following Islamic practices. Which of the following statements by the nurse indicates culturally responsive care to the client? A. I will make sure the menu includes kosher options B. I will ask the client if they want to schedule some times to pray during the day C. I will avoid discussing care when the client's family is around D. I will make sure daily communication is available for this client

B

A nurse is experiencing an ethical dilemma with a patient. Which information indicates the nurse has a correct understanding of the primary cause of ethical dilemmas? a. Unequal power b. Presence of conflicting values c. Judgmental perceptions of patients d. Poor communication with the patient

B

A nurse is preparing to provide hygiene care. Which principle should the nurse consider when planning hygiene care? A. hygiene care is always routine and expected B. no two individuals perform hygiene in the same manner C. it is important to standardize a pt's hygienic practices D. during hygiene care do not take the time to learn about pt needs

B

A nurse is providing a bath. In which order will the nurse clean the body, beginning with the first area? 1. Face 2. Eyes 3. Perineum 4. Arm and chest 5. Hands and nails 6. Back and buttocks 7. Abdomen and legs A. 1, 2, 5, 4, 7, 6, 3 B. 2, 1, 4, 5, 7, 3, 6 C. 2, 1, 5, 4, 6, 7, 3 D. 1, 2, 4, 5, 3, 7, 6

B

A nurse is providing presence to a pt and the family. Which nursing action does this involve? A. focusing on the task that needs to be done B. providing closeness and a sense of caring C. jumping in to provide pt comfort D. being there without an identified goal

B

A nurse is teaching a patient and family about quality of life. Which information should the nurse include in the teaching session about quality of life? a. It is deeply social. b. It is hard to define. c. It is an observed measurement for most people. d. It is consistent and stable over the course of one's lifetime.

B

A nurse is teaching about the therapy that is more effective in treating physical ailments than in preventing disease or managing chronic illness. Which therapy is the nurse describing? A. complementary B. allopathic C. alternative D. mind-body

B

A nurse is using caring-healing relationships to support whole person/whole systems healing. Which type of nursing is the nurse using? A. holistic nursing B. integrative nursing C. interprofessional nursing D. complementary and alternative nursing

B

A nurse provides AM care to pts. Which action will the nurse take? a. Soaks feet of patient with peripheral vascular disease b. Applies CHG solution to wash perineum of patient with a stroke c. Cleanses eye from outer canthus to inner canthus of patient with diabetes d. Uses long, firm stroke to wash legs of patient with blood-clotting disorder

B

A nursing assistive personnel (NAP) is caring for a dying patient. Which action by the NAP will cause the nurse to intervene? a. Elevating head of bed b. Making the patient eat c. Giving mouth care every 2 to 4 hours d. Keeping skin clean, dry, and moisturized

B

A patient is admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. Which arterial blood gas values will the nurse expect to observe? a. Respiratory alkalosis b. Metabolic alkalosis c. Metabolic acidosis d. Respiratory acidosis

B

A patient's hygiene schedule of bathing and brushing teeth is largely influenced by family customs. For which age group is the nurse most likely providing care? A. adolescent B. preschooler C. older adult D. adult

B

A previously toilet trained toddler has started wetting again. A nurse is gathering a health history from the grandparent. Which health history finding will the nurse most likely consider as the cause of the wetting? a. Dietary changes b. Recent parental death c. Playmate moved away d. Sibling was sick 2 days

B

A pt uses an in-the-canal hearing aid. Which assessment is a priority? A. eyeglass usage B. cerumen buildup C. type of physical exercise D. excessive moisture problems

B

A veteran is hospitalized after surgical amputation of both lower extremities owing to injuries sustained during military service. Which type of loss will the nurse focus the plan of care on for this patient? a. Perceived loss b. Situational loss c. Maturational loss d. Uncomplicated loss

B

An Orthodox Jewish rabbi has been pronounced dead. The nursing assistive personnel respectfully ask family members to leave the room and go home as postmortem care is provided. Which statement from the supervising nurse is best? a. "I should have called a male colleague to handle the body." b. "Family members stay with the body until burial the next day." c. "I wish they would go home because we have work to do here." d. "Family will quietly leave after praying and touching the rabbi's head."

B

During a follow-up visit, a female patient is describing new onset of marital discord with her terminally ill spouse to the hospice nurse. Which Kübler-Ross stage of dying is the patient experiencing? a. Denial b. Anger c. Bargaining d. Depression

B

During a severe respiratory epidemic, the local health care organizations decide to give health care workers priority access to ventilators over other members of the community who also need that resource. Which philosophy would give the strongest support for this decision? a. Deontology b. Utilitarianism c. Ethics of care d. Feminist ethics

B

In which patient will the nurse expect to see a positive Chvostek sign? A. a 7 y/o child admitted for servre burns B. 24 y/o adult admitted for chronic alcohol abuse C. 50 y/o pt admitted for acute exacerbation of hyperparathyroidism D. 75 y/o pt admitted for a broken hip r/t osteoporosis

B

The nurse has become aware of missing narcotics in the patient care area. Which ethical principle obligates the nurse to report the missing medications? a. Advocacy b. Responsibility c. Confidentiality d. Accountability

B

The patient's son requests to view documentation in the medical record. What is the nurse's best response to this request? a. "I'll be happy to get that for you." b. "You are not allowed to look at it." c. "You will need your mother's permission." d. "I cannot let you see the chart without a doctor's order."

C

The nurse is preparing to provide a complete bed bath to an unconscious patient. The nurse decides to use a bag bath. In which order will the nurse clean the body, starting with the first area? 1. Neck, shoulders, and chest 2. Abdomen and groin/perineum 3. Legs, feet, and web spaces 4. Back of neck, back, and then buttocks 5. Both arms, both hands, web spaces, and axilla A. 5, 1, 2, 3, 4 B. 1, 5, 2, 3, 4 C. 1, 5, 2, 4, 3 D. 5, 1, 2, 4, 3

B

The nurse is providing a complete bed bath to a patient using a commercial bath cleansing pack (bag bath). What should the nurse do? A. rinse throughly B. allow the skin to air dry C. do not use a bath towel D. dry the skin with a towel

B

The nurse is teaching a patient about contact lens care. Which instructions will the nurse include in the teaching session? A. use tap water to clean soft lenses B. wash and rinse lens storage case daily C. reuse storage solution for up to a week D. keep the lenses in a cool, dry place when not being used

B

The nurse is teaching the patient about flossing and oral hygiene. Which instruction will the nurse include in the teaching session? A. using waxed floss prevents bleeding B. flossing removes plaque and tartar from the teeth C. performing flossing at least 3 times a day is beneficial D. applying toothpaste to the teeth before flossing is harmful

B

The nurse observes that the patient's calcium is elevated. When checking the phosphate level, what does the nurse expect to see? A. increased B. decreased C. equal to calcium D. no change in phosphate

B

The nurse questions a health care provider's decision to not tell the patient about a cancer diagnosis. Which ethical principle is the nurse trying to uphold for the patient? a. Consequentialism b. Autonomy c. Fidelity d. Justice

B

The nurse receives the patient's most recent blood work results. Which laboratory value is of greatest concern? A. sodium of 145 mEq/L B. calcium of 15.5 mg/dL C. potassium of 3.5 mEq/L D. chloride of 100 mEq/L

B

The patient is afraid to have a thoracentesis at the bedside. The nurse sits with the patient and asks about the fears. During the procedure, the nurse stays with the patient, explaining each step and providing encouragement. What is the nurse displaying? A. providing touch B. providing a presence C. providing family care D. providing a listening ear

B

The patient is being fitted with a hearing aid. In teaching the patient how to care for the hearing aid, which instructions will the nurse provide? A. change the battery everyday or as needed B. adjust the volume for a talking distance of 1 yard C. wear the hearing aid 24 hours per day except when sleeping D. avoid the use of hairspray, but aerosol perfumes are allowed

B

The patient is terminal and very near death. When the nurse checks the patient and finds no pulse or blood pressure, the family begins sobbing and hugging each other. Some family members hold the patient's hand. The nurse is overwhelmed by the presence of grief and leaves the room. What is the nurse demonstrating? A. caring touch B. protective touch C. therapeutic touch D. task-oriented touch

B

When professionals work together to solve ethical dilemmas, nurses must examine their own values. What is the best rationale for this step? a. So fact is separated from opinion b. So different perspectives are respected c. So judgmental attitudes can be provoked d. So the group identifies the one correct solution

B

When providing hygiene for an older-adult patient, the nurse closely assesses the skin. What is the rationale for the nurse's action? A. outer skin layer becomes more resilient B. less frequent bathing may be required C. .skin becomes less subject to bruising D. sweat glands become more active

B

Which action indicates a nurse is using caring touch with a pt? A. inserts a catheter B. rubs a pt's back C. prevents a pt from falling D. administers and injection

B

Which blood gas result will the nurse expect to observe in a patient with respiratory alkalosis? a. pH 7.60, PaCO2 40 mm Hg, HCO3- 30 mEq/L b. pH 7.53, PaCO2 30 mm Hg, HCO3- 24 mEq/L c. pH 7.35, PaCO2 35 mm Hg, HCO3- 26 mEq/L d. pH 7.25, PaCO2 48 mm Hg, HCO3- 23 mEq/L

B

A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and programs the pump to infuse at 50 mL/hr. At what time should the infusion be completed? a. 2300 Monday b. 2345 Monday c. 0015 Tuesday d. 0045 Tuesday

B 250 mL / 50 mL = 5 hr 1845 + 5 hr = 2345 on Monday

A nurse is using Watson's model to provide care to pts. Which carative factor will the nurse use? A. maintaining belief B. instilling faith-hope C. maintaining ethics D. instilling values

B Watson has 10 carative factors and this is one of them

A nurse on the med surg unit is caring for a group of clients. For which of the following clients should the nurse expect a prescription for fluid restriction? A. a client who has a new diagnosis of adrenal insufficiency B. a client who has heart failure C. a client who is receiving treatment for diabetic ketoacidosis D. a client who has abdominal ascites

B a client with HF has to require fluid and sodium restriction to reduce the workload on the heart

A nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take? A. pull down and out at the back of the upper denture to remove B. brush the dentures with a toothbrush and denture cleaner C. rinse the dentures with hot water after cleaning them D. place the dentures in a clean, dry storage container after cleaning them

B brushing throughly with a toothbrush and denture cleaner removes the debris that accumulates on and between the teeth

A nurse is administering a blood transfusion. Which assessment finding will the nurse report immediately? a. Blood pressure 110/60 b. Temperature 101.3° F c. Poor skin turgor and pallor d. Heart rate of 100 beats/min

B fever should be reported immediately and blood transfusions should be stopped

A nurse is caring for a client who decides not to have surgery despite significant blockages of the coronary arteries. The nurse understands that this client's choice is an example of which of the following? A. fidelity B. autonomy C. justice D. non-maleficence

B the client is exercising their right to make their own personal decision about surgery and what is best for them

A nurse is planning to use healing intention with a client who is recovering from a lengthy illness. Which of the following is the priority action to take before attempting this particular mind-body intervention? A. tell the client the goal of therapy is to promote healing B. ask whether the client is comfortable with using prayer C. encourage the client participate actively for best results D. instruct the client to relax during the therapy

B the first action to take during nursing process is assessment and the nurse must first determine the client is comfortable with a therapy that involves prayer

The nurse is caring for a patient with cognitive impairments. Which actions will the nurse take during AM care? (Select all that apply.) a. Administer ordered analgesic 1 hour before bath time. b. Increase the frequency of skin assessment. c. Reduce triggers in the environment. d. Keep the room temperature cool. e. Be as quick as possible.

B, C

A nurse is collecting data from a client who has hypercalcemia as a result of long-term use of glucocorticoids. Which of the following findings should the nurse expect? (select all that apply) A. hyperreflexia B. confusion C. positive chvostek's sign D. bone pain E. nausea and vomiting

B, D, E

A nurse is documenting end-of-life care. Which information will the nurse include in the patient's electronic medical record? (Select all that apply.) a. Reason for the death b. Time and date of death c. How ethically the family grieved d. Location of body identification tags e. Time of body transfer and destination

B, D, E

A nurse is using an interpreter to communicate with a client. Which of the following actions should the nurse use when communicating with a client and family members? (Select all that apply) A. talk to the interpreter about the family while the family is in the room B. determine the client's understanding several times during the conversation C. look at the interpreter while asking the family questions D. use lay terms if possible E. do not interrupt the interpreter and the family as they talk

B, D, E

A nurse is discontinuing a patient's peripheral IV access. Which actions should the nurse take?(Select all that apply.) a. Wear sterile gloves and a mask. b. Stop the infusion before removing the IV catheter. c. Use scissors to remove the IV site dressing and tape. d. Apply firm pressure with sterile gauze during removal. e. Keep the catheter parallel to the skin while removing it. f. Apply pressure to the site for 2 to 3 minutes after removal.

B, E, F

The patient reports to the nurse about a perceived decrease in hearing. When the nurse examines the patient's ear, a large amount of cerumen buildup at the entrance to the ear canal is observed. Which action will the nurse take next? A. teach the pt how to use cotton-tipped applicators B. tell the pt to use a bobby pin to extract earwax C. apply gentle, downward retraction of the ear canal D. instill hot water into the ear canal to melt the wax

C

A nurse is using the holistic approach to care. Which goal is the priority? a. Integrate spiritual treatments. b. Join physical care with a vegan diet. c. Incorporate the mind-body-spirit connection. d. Use complementary and alternative therapies.

C

A patient asks about the new clinic in town that is staffed by allopathic and complementary practitioners. Which response from the nurse is best? A. it is probably an ayurvedic clinic B. it is probably a homeopathic clinic C. it is probably an integrative medical clinic D. it is probably a naturopathic medical clinic

C

A patient is to receive 1000 mL of 0.9% sodium chloride intravenously at a rate of 125 mL/hr. The nurse is using microdrip gravity drip tubing. Which rate will the nurse calculate for the minute flow rate (drops/min)? a. 12 drops/min b. 24 drops/min c. 125 drops/min d. 150 drops/min

C

A patient presents to the emergency department with reports of vomiting and diarrhea for the past 48 hours. The health care provider orders isotonic intravenous (IV) therapy. Which IV will the nurse prepare? a. 0.225% sodium chloride (1/4 NS) b. 0.45% sodium chloride (1/2 NS) c. 0.9% sodium chloride (NS) d. 3% sodium chloride (3% NaCl)

C

"I know it seems strange, but I feel guilty being pregnant after the death of my son last year," said a woman during her routine obstetrical examination. The nurse spends extra time with this woman, helping her realize bonding with this unborn child will not mean she is replacing the one who died. Which nursing technique does this demonstrate? a. Providing curative therapy b. Promoting spirituality c. Facilitating mourning d. Eradicating grief

C

A female nurse is called into the supervisor's office regarding her deteriorating work performance since the loss of her spouse 2 years ago. The woman begins sobbing and says that she is "falling apart" at home as well. Which type of grief is the female nurse experiencing? a. Normal grief b. Perceived grief c. Complicated grief d. Disenfranchised grief

C

A nurse agrees with regulations for mandatory immunizations of children. The nurse believes that immunizations prevent diseases as well as prevent spread of the disease to others. Which ethical framework is the nurse using? a. Deontology b. Ethics of care c. Utilitarianism d. Feminist ethics

C

A nurse enters a patient's room, arranges the supplies for a Foley catheter insertion, and explains the procedure to the patient. She tells the patient what to expect; just before inserting the catheter, she tells the patient to relax and that, once the catheter is in place, she will not feel the bladder pressure. The nurse then proceeds to skillfully insert the Foley catheter. This is an example of what type of touch? A) Caring touch B) Protective touch C) Task-oriented touch D) Interpersonal touch

C

A nurse enters the room of a client who is crying while reading from a religious book and asks to be left alone. Which of the following actions should the nurse take? A. contact the hospital's spiritual services B. ask what is making the client cry C. ensure no visitors or staff enter the room for a short period of time D. turn on the TV for a distraction

C

A nurse has just received a bag of packed red blood cells (RBCs) for a patient. What is the longest time the nurse can let the blood infuse? a. 30 minutes b. 2 hours c. 4 hours d. 6 hours

C

A nurse is caring for a cancer patient who presents with anorexia, blood pressure 100/60, and elevated white blood cell count. Which primary purpose for starting total parenteral nutrition (TPN) will the nurse add to the care plan? a. Stimulate the patient's appetite to eat. b. Deliver antibiotics to fight off infection. c. Replace fluid, electrolytes, and nutrients. d. Provide medication to raise blood pressure.

C

A nurse is caring for a client who has stage IV lung cancer and is 3 days post-op following a wedge resection. The client states, "I told myself that I would go through with the surgery and quit smoking, if I could just live long enough to attend my child's wedding." Based on the Kübler-Ross model, which stage of grief is the client experiencing? 1. anger 2. denial 3. bargaining 4. acceptance

C

A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family assisting with all the ADLs. Which of the following rationales for self-care should the nurse communicate to the family? A. allowing the client to function independently will strengthen muscles and promote healing B. the client needs privacy at times for self-reflecting and organizing life C. the client's sense of loss can be lessened through retaining control of some areas of life D. performing ADLs is a requirement prior to discharge from an acute care facility

C

A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care for these clients? A. members of the same religion share similar feelings about their religion B. a shared religious background generates mutual regard for one another C. the same religious beliefs can influence individuals differently D. the nurse and client should discuss the differences and commonalities in their beliefs

C

A nurse is discussing quality of life issues with another colleague. Which topic will the nurse acknowledge for increased attention paid to quality of life concerns? a. Health care disparities b. Aging of the population c. Abilities of disabled persons d. Health care financial reform

C

A nurse is instructing a group of newly licensed nurses about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the newly licensed nurses identify as an ethical dilemma? A. A nurse on a medical-surgical unit demonstrates signs of chemical impairment B. A nurse overhears another nurse telling an older adult client that if he doesn't stay in bed, she will have to apply restraints C. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill D. A client who is terminally ill hesitates to name their partner on their durable power of attorney

C

A nurse is preparing to start a blood transfusion. Which type of tubing will the nurse obtain? a. Two-way valves to allow the patient's blood to mix and warm the blood transfusing b. An injection port to mix additional electrolytes into the blood c. A filter to ensure that clots do not enter the patient d. An air vent to let bubbles into the blood

C

A nurse is providing perineal care to a female patient. Which washing technique will the nurse use? A. back to front B. in a circular motion C. from pubic area to rectum D. upward from rectum to pubic area

C

A nurse is teaching a patient relaxation techniques to decreases stress. Which finding will support the nurse's evaluation that the therapy is effective? A. dilated pupils B. increased blood sugar C. decreased heart rate D. elevated blood pressure

C

An older-adult patient is newly admitted to a skilled nursing facility with the diagnoses of Alzheimer's dementia, lipidemia, and hypertension, and a history of pulmonary embolism. Medications brought on admission included lisinopril (Zestril, Prinivil), hydrochlorothiazide (Microzide), warfarin (Coumadin), low-dose aspirin, ginkgo biloba, and echinacea. Which potential interaction will cause the nurse to notify the patient's health care provider? A. echinacea and warfarin B. lisinopril and echinacea C. warfarin and gingko biloba D. lisinopril and hydrochlorothiazide

C

Family members gather in the emergency department after learning that a family member was involved in a motor vehicle accident. After learning of the family member's unexpected death, the surviving family members begin to cry and scream in despair. Which phase does the nurse determine the family is in according to the Attachment Theory? a. Numbing b. Reorganization c. Yearning and searching d. Disorganization and despair

C

Presence involves a person-to-person encounter that: A) Enables patients to care for self. B) Provides personal care to a patient. C) Conveys a closeness and a sense of caring. D) Describes being in close contact with a patient.

C

The female nurse is caring for a male patient who is uncircumcised but not ambulatory and has full function of all extremities. The nurse is providing the patient with a partial bed bath. How should perineal care be performed for this patient? A. should be postponed because it may cause embarrassment B. should be unnecessary because the pt is uncircumcised C. should be done by the pt D. should be done by the nurse

C

The health care provider asks the nurse to monitor the fluid volume status of a heart failure patient and a patient at risk for clinical dehydration. Which is the most effective nursing intervention for monitoring both of these patients? a. Assess the patients for edema in extremities. b. Ask the patients to record their intake and output. c. Weigh the patients every morning before breakfast. d. Measure the patients' blood pressures every 4 hours.

C

The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. Which action will the nurse take first? a. Offer calcium-rich foods. b. Administer diuretic. c. Raise head of bed. d. Increase fluids.

C

The nurse is caring for a dying patient. Which intervention is considered futile? a. Giving pain medication for pain b. Providing oral care every 5 hours c. Administering the influenza vaccine d. Supporting lower extremities with pillows

C

The nurse is caring for a patient who has been sullen and quiet for the past three days. Suddenly, the patient says, "I'm really nervous about surgery tomorrow, but I'm more worried about how it will affect my family." What should the nurse do first? A. assure the pt that everything will be alright B. tell the pt that there is no need to worry C. listen to the pt's concerns and fears D. inform the pt a social worker is available

C

The nurse is caring for a patient who is immobile. The nurse frequently checks the patient for impaired skin integrity. What is the rationale for the nurse's action? A. inadequate blood flow leads to decreased tissue ischemia B. pts with limited caloric intake develop thicker skin C. pressure reduces circulation to affected tissue D. verbalization of skin care needs is decreased

C

The nurse is caring for a patient who is reporting severe foot pain due to corns. The patient has been using oval corn pads to self-treat the corns, but they seem to be getting worse. Which information will the nurse share with the patient? A. corn pads are an adequate treatment and should be continued B. the pt should avoid soaking the feet before using a pumice stone C. depending on severity, surgery may be needed to remove the corns. D. tighter shoes would help to compress the corns and make them smaller

C

The nurse is caring for a patient with diabetes. Which task will the nurse assign to the nursing assistive personnel? A. providing nail care B. teaching foot care C. making an occupied bed D. determining aspiration risk

C

The nurse is evaluating the effectiveness of the intravenous fluid therapy in a patient with hypernatremia. Which finding indicates goal achievement? a. Urine output increases to 150 mL/hr. b. Systolic and diastolic blood pressure decreases. c. Serum sodium concentration returns to normal. d. large amounts of emesis and diarrhea decrease

C

The nurse is providing oral care to a patient. In which order will the nurse clean the oral cavity, starting with the first area? 1. Roof of mouth, gums, and inside cheek 2. Chewing and inner tooth surfaces 3. Outer tooth surfaces 4. Tongue A. 4, 1, 3, 2 B. 3, 2, 4, 1 C. 2, 3, 1, 4 D. 1, 4, 2, 3

C

The nurse is providing perineal care to an uncircumcised male patient. Which action will the nurse take? A. leave the foreskin alone because there is little chance of infection B. retract the foreskin for cleansing and allow it to return on its own C. retract the foreskin and return it to its natural position when done D. leave the foreskin retracted

C

The nurse is teaching the parents of a child who has head lice (pediculosis capitis). Which information will the nurse include in the teaching session? A. treatment is use of regular shampoo B. products containing lindane are most effective C. head lice may spread to furniture and other people D. manual removal is not a realistic option as treatment

C

The nurse observes edema in a patient who has venous congestion from right heart failure. Which type of pressure facilitated the formation of the patient's edema? A. osmotic B. oncotic C. hydrostatic D. concentration

C

The patient has been diagnosed with diabetes. When admitted, the patient is unkempt and is in need of a bath and foot care. When questioned about hygiene habits, the nurse learns the patient takes a bath once a week and a sponge bath every other day. To provide ultimate care for this patient, which principle should the nurse keep in mind? A. pts who appear unkempt place little importance on hygiene practices B. personal preferences determine hyigene practices and are unchangeable C. the pt's illness may require teaching of new hygiene practices D. all cultures value clealiness with the same degree of importance

C

The pt has a colostomy but has not yet been able to look at it. The nurse teaches the pt how to care for the colostomy. The nurse sits with the pt and together they form a plan on how to approach dealing with colostomy care. Which caring process is the nurse performing? A. knowing B. doing for C. enabling D. maintaining belief

C

Which instruction will the nurse provide to the nursing assistive personnel when providing foot care for a patient with diabetes? A. do not place slippers on the pt's feet B. trim the pt's toenails daily C. report sores on the pt's toes D. check the brachial artery

C

While the nurse is taking a patient history, the nurse discovers the patient has a type of diabetes that results from a head injury and does not require insulin. Which dietary change should the nurse share with the patient? a. Reduce the quantity of carbohydrates ingested to lower blood sugar. b. Include a serving of dairy in each meal to elevate calcium levels. c. Drink plenty of fluids throughout the day to stay hydrated. d. Avoid food high in acid to avoid metabolic acidosis.

C

A nurse is instructing a group of newly licensed nurses about the responsibilities organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the newly licensed nurses should understand that this aspect of care delivery is an example of which of the following ethical principles? A. fidelity B. autonomy C. justice D. non-maleficence

C Is fairness in care delivery and in the use of resources

A patient is taking an antidepressant medication. The nurse discovers that the patient uses herbs. Which herb will cause the nurse to intervene? A. aloe B. garlic C. chamomile D. saw palmetto

C causes excessive drowsiness

The patient must stay in bed for a bed change. Which actions will the nurse implement? (Select all that apply.) a. Apply sterile gloves. b. Keep soiled linen close to uniform. c. Advise patient will feel a lump when rolling over. d. Turn clean pillowcase inside out over the hand holding it. e. Make a modified mitered corner with sheet, blanket, and spread.

C, D, E

A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? (Select all that apply) A. distended neck veins B. hyperthermia C. tachycardia D. syncope E. decreased skin turgor

C, D, E all these are expected findings for hypovolemia

A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Beneficence

D is the action that promotes good for others without any self-interest. in this case the nurse is taking a specific positive action to help the client.

A nurse is assisting the health care provider in inserting a central line. Which action indicates the nurse is following the recommended bundle protocol to reduce central line-associated bloodstream infections (CLABSI)? a. Preps skin with povidone-iodine solution. b. Suggests the femoral vein for insertion site. c. Applies double gloving without hand hygiene. d. Uses chlorhexidine skin antisepsis prior to insertion.

D

A nurse is caring for a client who has a terminal illness. Death is expected within 24 hr. The client's family is at the bedside and asks the nurse what to expect at this time. Which of the following findings should the nurse include? A. regular breathing patterns B. warm extremities C. increased urine output D. decreased muscle tone

D

A nurse is caring for a client who tells the nurse that based on religious values and mandates, a blood transfusion is not an acceptable treatment option. Which of the following responses should the nurse make? A. I believe in this case you should really make an exception and accept the blood transfusion B. I know your family would approve of your decision to have a blood transfusion C. Why does your religion mandate that you cannot receive any blood transfusions D. Let's discuss the necessity for a blood transfusion with your spiritual and religious leaders and come to a reasonable solution

D

A nurse is caring for a dying patient. One of the nurse's goals is to promote dignity and validation of the dying person's life. Which action will the nurse take to best achieve this goal? a. Take pictures of visitors. b. Provide quiet visiting time. c. Call the organ donation coordinator. d. Listen to family stories about the person.

D

A nurse is caring for a patient in the last stages of dying. Which finding indicates the nurse needs to prepare the family for death? a. Redness of skin b. Clear-colored urine c. Tense muscles tone d. Cheyne-Stokes breathing

D

A nurse is caring for a patient who is receiving peripheral intravenous (IV) therapy. When the nurse is flushing the patient's peripheral IV, the patient reports pain. Upon assessment, the nurse notices a red streak that is warm to the touch. What is the nurse's initial action? a. Record a phlebitis grade of 4. b. Assign an infiltration grade. c. Apply moist compress. d. Discontinue the IV.

D

A nurse is completing an assessment of the patient. Which principle is a priority? A. foot care will always be important B. daily bathing will always be important C. hygiene needs will always be important D. critical thinking will always be important

D

A nurse is emphasizing the use of touch to decrease "skin hunger" in caring for patients. Which age group is the nurse primarily describing? A. infants B. children C. middle age D. older adults

D

A nurse is preparing to start peripheral intravenous (IV) therapy. In which order will the nurse perform the steps starting with the first one? 1. Clean site. 2. Select vein. 3. Apply tourniquet. 4. Release tourniquet. 5. Reapply tourniquet. 6. Advance and secure. 7. Insert vascular access device. A. 1, 3, 2, 7, 5, 4, 6 B. 1, 3, 2, 5, 7, 6, 4 C. 3, 2, 1, 5, 7, 6, 4 D. 3, 2, 4, 1, 5, 7, 6

D

A nurse is providing different types of therapies to a patient with excessive fatigue and cancer. Which technique will cause the nurse manager to intervene? A. meditation B. guided imagery C. passive relaxation D. active progressive relaxation

D

A nurse is teaching a patient about the use of biofeedback. Which goal should the nurse add to the care plan? A. opens emotional channels B. uses music to calm the mind C. holds various postures with breathing D. controls autonomic physiological functions

D

A nurse lets the transplant coordinator make a request for organ and tissue donation from the patient's family. What is the primary rationale for the nurse's action? a. The nurse is not as knowledgeable as the coordinator. b. The nurse is uncomfortable asking the family. c. The nurse does not want to upset the family. d. The nurse is following a federal law.

D

A nurse must make an ethical decision concerning vulnerable patient populations. Which philosophy of health care ethics would be particularly useful for this nurse? a. Teleology b. Deontology c. Utilitarianism d. Feminist ethics

D

A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence

D

A nursing assistive personnel (NAP) is providing AM care to patients. Which action by the NAP will require the nurse to intervene? A. not offering a backrub to a pt with fractured ribs B. not offering to wash the hair of a pt with neck trauma C. turning off the TV while giving a backrub to the pt D. turning the pt's head with neck injury to side when giving oral care

D

A palliative team is caring for a dying patient in severe pain. Which action is the priority? a. Provide postmortem care for the patient. b. Support the patient's nurse in grieving. c. Teach the patient the stages of grief. d. Enhance the patient's quality of life.

D

A patient cancels a scheduled appointment because the patient will be attending a Shivah for a family member. Which response by the nurse is best? a. "When families come together for end-of-life decisions, it provides connections." b. "We will reschedule so the appointment does not fall on the Sabbath." c. "Missionary outreach is so important for spiritual comfort." d. "I'm so sorry for your loss."

D

A patient has an acute intravascular hemolytic reaction to a blood transfusion. After discontinuing the blood transfusion, which is the nurse's next action? a. Discontinue the IV catheter. b. Return the blood to the blood bank. c. Run normal saline through the existing tubing. d. start normal saline at TKO rate using new tubing

D

A patient's father died a week ago. Both the patient and the patient's spouse talk about the death. The patient's spouse is experiencing headaches and fatigue. The patient is having trouble sleeping, has no appetite, and gets choked up most of the time. How should the nurse interpret these findings as the basis for a follow-up assessment? a. The patient is dying and the spouse is angry. b. The patient is ill and the spouse is malingering. c. Both the patient and the spouse are likely in denial. d. Both the patient and the spouse are likely grieving.

D

A terminally ill patient is experiencing constipation secondary to pain medication. Which is the best method for the nurse to improve the patient's constipation problem? a. Contact the health care provider to discontinue pain medication. b. Administer enemas twice daily for 7 days. c. Massage the patient's abdomen. d. Use a laxative.

D

A young woman who is pregnant with a fetus exposed to multiple teratogens consents to have her fetus undergo serial PUBS (percutaneous umbilical blood sampling) to examine how exposure affects the fetus over time. Although these tests will not improve the fetus's outcomes and will expose it to some risks, the information gathered may help infants in the future. Which ethical principle is at greatest risk? a. Fidelity b. Autonomy c. Beneficence d. Nonmaleficence

D

During a relaxation therapy skills group, the instructor discusses the cognitive skill of learning to tolerate uncertain and unfamiliar experiences. Which skill is the nurse describing? A. passivity B. focusing C. mindfulness D. receptivity

D

Listening is not only "taking in" what a patient says; it also includes: A) Incorporating the views of the physician. B) Correcting any errors in the patient's understanding. C) Injecting the nurse's personal views and statements. D) Interpreting and understanding what the patient means.

D

On entering a room the nurse sees the patient crying softly. What is the most therapeutic response? A. Using silence B. Asking, "Why are you crying today?" C. Using therapeutic touch D. Stating, "I see that you're crying"

D

The nurse is caring for a patient supported with a ventilator who has been unresponsive since arrival via ambulance 8 days ago. The patient has not been identified, and no family members have been found. The nurse is concerned about the plan of care regarding maintenance or withdrawal of life support measures. Place the steps the nurse will use to resolve this ethical dilemma in the correct order. 1. The nurse identifies possible solutions or actions to resolve the dilemma. 2. The nurse reviews the medical record, including entries by all health care disciplines, to gather information relevant to this patient's situation. 3. Health care providers use negotiation to redefine the patient's plan of care. 4. The nurse evaluates the plan and revises it with input from other health care providers as necessary. 5. The nurse examines the issue to clarify opinions, values, and facts. 6. The nurse states the problem. a. 6, 1, 2, 5, 4, 3 b. 5, 6, 2, 3, 4, 1 c. 1, 2, 5, 4, 3, 6 d. 2, 5, 6, 1, 3, 4

D

The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority? a. Gastrointestinal b. Neurological c. Respiratory d. Cardiac

D

The nurse is providing education about the importance of proper foot care to a pt who has DM. Which primary goal is the nurse trying to achieve? A. prevention of plantar warts B. prevention of foot fungus C. prevention of neuropathy D. prevention of amputation

D

The nurse is providing oral care to an unconscious patient. Which action should the nurse take? A. moisten the mouth using lemon-glycerin sponges B. hold the pt's mouth open with gloved fingers C. use foam swabs to help remove plaque D. suction the oral cavity

D

The nurse values autonomy above all other principles. Which patient assignment will the nurse find most difficult to accept? a. Older-adult patient who requires dialysis b. Teenager in labor who requests epidural anesthesia c. Middle-aged father of three with an advance directive declining life support d. Family elder who is making the decisions for a young-adult female member

D

The patient is being treated for cancer with weekly radiation therapy to the head and chemotherapy treatments. Which assessment is the priority? A. feet B. nail beds C. perineum D. oral cavity

D

Which action by the nurse will be the most important for preventing skin impairment in a mobile patient with local nerve damage? A. insert an indwelling urinary catheter B. limit caloric and protein intake C. turn the pt every 2 hours D. assess for pain during a bath

D

Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL? a. Weak quadriceps muscles b. Decreased deep tendon reflexes c. Light-headedness when standing up d. Tingling of extremities with possible tetany

D

In preparation for the eventual death of a female hospice patient of the Muslim faith, the nurse organizes a meeting of all hospice caregivers. A plan of care to be followed when this patient dies is prepared. Which information will be included in the plan? a. Prepare the body for autopsy. b. Prepare the body for cremation. c. Allow male Muslims to care for the body after death has occurred. d. Allow female Muslims to care for the body after death has occurred.

D Muslims of the same gender prepare the body for burial

A nurse is providing education for a client who has severe hypomagnesemia and is prescribed oral magnesium sulfate. Which of the following information should the nurse include in teaching? A. avoid green leafy vegetables while taking this med B. you should receive a prescription for thiazide diuretic to take with your magnesium C. you should eliminate whole grains from your diet until your magnesium level increases D. report diarrhea while taking this medication

D This is a potential adverse effect and could worsen the client's hypomagnesemia

A patient describes practicing a complementary and alternative therapy involving breathwork and yoga. The nurse also recommends using energy field therapies. Which techniques did the nurse suggest? A. prayer and tai chi B. the zone and acupressure C. massage therapy and ayurveda D. reiki therapy and therapeutic touch

D these are energy field therapies