NUR 461 EXAM 1 Prep U Questions

A client who underwent a hysterectomy 4 days ago says to the nurse, "I wonder if I'll still feel like a woman." Which response would most likely encourage the client to expand on this and express concerns in more specific terms?

"Feel like a woman..." -The best response of the options listed is the statement "Feel like a woman..." This response is a reflective comment, which allows the client to reflect and elaborate on feelings. Remaining silent is a skill that is appropriate many times, but not the most appropriate in the situation at hand. Asking a yes/no question such as "Do you want more children?" or "Do you feel like you are not a woman?" does not encourage the client to reflect and elaborate on feelings.

The client confronts the nurse, stating, "No one has come into my room to give me the pain medication I requested 2 hours ago. I am in pain!" Which response by the nurse indicates the nurse is using a "defending" communication technique?

"I have been busy with other clients that required my immediate attention." - The nurse is demonstrating defending behaviors and statements when attempting to justify the reason for not returning with a client's pain medication. This response places the client in the defensive stance as well.

The nurse has arranged to start an IV line for a client with pancreatitis. The nurse notes that the client appears anxious about the procedure. What is the most appropriate response by the nurse to decrease the client's anxiety?

"I will start an IV that will add fluids directly to the blood stream." -The nurse should explain the procedure and its purpose. The nurse telling the client that it should not take much time does not convey the purpose of the procedure.

A nurse is caring for a client with depression. The nurse finds that the client is withdrawn and does not communicate with others. What is the most appropriate response by the nurse?

"Is that a new shirt that you're wearing ?" -When the client is not talking, the nurse should use the observation technique of therapeutic communication. The nurse should complement the client to get the client's attention. Wearing a new shirt is an observation about the client that would draw communication from the client. The nurse should avoid direct questions to a client who is experiencing depression.

The unlicensed assistive personnel (UAP) has taken vital signs on a newly admitted client. The client asks the nurse how this information is recorded in the chart, since the UAP is not licensed. Which response by the nurse is best?

"The UAP is able to log in and enter the information so all members of the health care team can see it." - Each person who makes entries in the client's electronic health record (EHR) is responsible for the information he or she records and can be summoned as a witness to testify concerning what has been documented. Although the licensed registered nurse has accountability, the UAP can document data that has been collected in the EHR. It is not appropriate to document for someone else, and all users should always log out of the computer prior to allowing another person to document.

The nursing student is discussing the need for a care plan with the instructor. What is the most appropriate explanation by the instructor for nursing care plan development?

"The care plan is required for every client by The Joint Commission." -The Joint Commission's standards require that the record show evidence of a plan of care. Many agencies require a separate nursing care plan as a means of demonstrating compliance. Nurses revise the plan of care as the client's condition changes. The other responses are not reflective of this standard.

The nurse has finished teaching a client about medications that have been prescribed for administration. Which client statement reflects that teaching about a piggyback infusion of antibiotics has been successful?

-"When I am out of bed the small IV bag must not be lower than the large IV bag. Most infusion sets include back-check valves that stop primary (large IV bag) IV solution flow while medication infuses and then automatically open when medication (small IV bag) or piggyback infusion stops. When using these devices, the secondary bag is hung at the level of or higher than the primary bag.

The nurse is taking verbal medication prescriptions from the provider by hand to be documented in the clients eMAR for administration of medication. How should the nurse correctly document this information?

0800-Amoxicillin 250mg PO with water. J. Doe, RN. -When documenting information in a client's health care record, the nurse should sign each entry by name, first initial and last name, and title. Correct documentation also includes recognition of those abbreviations and terms on the "Do Not Use" list such as "per os" and "OJ" which can be confused with other terminology meanings. Time stamps should also be included in documentation.

A nurse is preparing to irrigate an intermittent infusion device. Which size syringe would the nurse use?

10 mL -To prevent blood clot formation, the devices are irrigated with a small quantity (3 mL) of sterile, preservative-free sodium chloride (NaCl) from a large-barrel (10 mL) syringe. The large-barrel syringe is used to decrease pressure during irrigation and hence decrease the risk of catheter damage.

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

Assume body position with eye level and continue interview -When communicating with most clients, it is best to position oneself at the client's level and make frequent eye contact. Eye contact is perhaps among the most culturally variable nonverbal behaviors, and can be misunderstood as embarrassment, nervousness, or a problem with the client.

A nurse needs to administer a subcutaneous injection to a client. How far from the previous injection site to the area should the nurse administer the injection?

At least 1 inch -Injection sites are rotated a finger's width apart, or about 1 inch (2.5 cm), from a previous site to avoid repeatedly injecting into the same area in a short amount of time. Rotating sites avoids tissue injury.

An older adult client has been receiving care in a two-bed room that he has shared with another older, male client for the past several days. Two days ago, the client's roommate developed diarrhea that was characteristic of Clostridium difficile. This morning, the client himself was awakened early by similar diarrhea. The client may have developed which type of infection?

Exogoneous Health-Care acquired infection -The client's suspected infection originated with another person (exogenous) and was contracted in the hospital (healthcare-associated). It was not the result of his treatment (iatrogenic) and C. difficile is not an antibiotic-resistant microorganism. Endogenous infections originate from within the organism and are not attributed to an external or environmental factor.

A nurse finds that a client has infiltration around the IV line that needs to be removed. What explanation should the nurse give to reduce the client's anxiety?

I know that you are anxious. But the IV location needs to be changed -The nurse uses therapeutic communication by both acknowledging the client's anxiety and giving honest information that another IV line needs to be started. Telling the client that infiltration is causing pain but will be relieved upon removal of the IV line does not address the client's anxiety and does not inform the client about restarting another IV line. Also, the nurse telling the client to take deep breaths, or stating that the procedure is minimal and will be over soon, does not consider the client's anxiety. Finally, telling the client that "many clients experience this" is generalizing and is not appropriate.

Which statement about neonatal development is accurate?

Neonates may have infection without a fever -Newborns have immature thermoregulatory mechanisms and do not become febrile.

A client is having an open cholecystectomy and requires a saline irrigation. What action will reduce the spread of pathogens to the client and other clients?

Pour a small amount of solution out of the container prior to pouring it into the sterile basin -When using a sterile solution, the circulating nurse should pour the solution from above the waist level and avoid splashing the solution onto the sterile field and avoid touching any sterile areas within the field. The nurse should pour and discard a small amount of solution to wash away airborne contaminants. The unused solution should be discarded and not used in the future either for the surgical client or any other client.

During hospitalization, the client has developed shortness of breath with edema. What action should the nurse take?

Revise the care plan - A plan of care should be generated at admission and reviewed regularly. The care plan must be revised to reflect changes in the client's condition. Changes in the care plan will then reflect new interventions to address those changes

The nurse is teaching a client with diabetes how to withdraw insulin from a vial. In which order should the nurse explain the steps to the client?

Select appropriate syringe and needle. Remove the metal cover from the rubber stopper. Fill the syringe with a volume of air equal to the volume that will be withdrawn from the vial. Pierce the rubber stopper with the needle and instill the air. Invert the vial, hold, and brace it while pulling on the plunger. Date and initial the vial for future use. -

A nurse is interviewing a client for the establishment of long-term care insurance. During the interview, the nurse asks questions regarding the client's past medical history. In this case, the nurse plays the role in the process of communication of the:

Sender -The nurse is playing the role of the sender, which is a person or group who has a purpose for the communication and initiates and conveys the message. The receiver, or decoder, is the person or group who receive and interpret, or decode, the message.

A nurse is attempting to communicate with a client who speaks a different language and is not fluent in the nurse's language. Which nursing action would best facilitate the communication process?

Speak slowly and distinctively. But not loudly -The best nursing action to facilitate the communication process would be to speak slowly and distinctly, but not loudly. Repeating the message multiple times would not be beneficial. Finding another way to convey the message would be more likely to be helpful. There may be cultural differences in nonverbal communication, for example, direct eye contact in some cultures is considered rude or threatening in other cultures. The use of a language dictionary could be beneficial in facilitating the conversation.

A nurse needs to withdraw a prescribed medication from an ampule and administer it to a client. Which action should the nurse perform to ensure that all the medication is equally distributed when withdrawing?

Tap the top of the ampule before withdrawing the medicine -Tapping the top of the ampule distributes all the medication to the lower portion of the ampule. Tapping the barrel of the syringe near the hub does not distribute medication equally, but moves the air toward the needle. Inserting the filter needle in the ampule ensures sterility of the needle. Using a smaller- or larger-gauge needle does not ensure that all the medication is equally distributed when withdrawing.

Which statement regarding FOCUS charting is most accurate?

The charting focuses on client strengths, problems, or needs -FOCUS charting focuses on client strengths, problems, or needs. The injury or illness is not the only focus of this form of charting.

A nurse is reviewing the white blood cell (WBC) count and differential of a client and notes that there is a significant shift to the left. The nurse interprets this as indicating:

The client has developed a bacterial infection - A shift to the left, or leftward shift in the granulocytic differential count, is considered a strong indicator of bacterial infection, not a viral infection. This shift occurs when an infection is severe or prolonged and the body cannot manufacture neutrophils quickly enough, resulting in the release of immature granulocytes into the blood. The greater the shift, the more worrisome the infection appears. When the proportion of neutrophils increases, the client's resistance is good and the body is considered to be fighting the infection well.

Which technique would a nurse employ when using listening skills appropriately when interviewing a client?

The nurse would listen to the themes in the client's comments -The technique that a nurse would employ when using listening skills would be to listen to the themes in the client's comments. The nurse would not stand close to the client and maintain eye contact in all situations of listening. The nurse would possibly use positive body gestures and nonverbal communication when listening. The nurse could use periods of silence in therapeutic communication to allow the client to reflect.

Which statement accurately describes the concept of feedback as it pertains to the process of communication?

The sender and the receiver use one another's reactions to produce further messages. -Feedback is a person's reactions to a message that provide evidence that the person has understood the intended message. Based on one's feedback during communication, the other party can produce further messages.

A nurse is caring for a client with scabies for which a topical medication has been prescribed. When educating the client on how to use the medication, which should the nurse tell the client regarding the application?

Use gloves to apply - The nurse should tell the client that the drug is to be administered by application on the skin wearing gloves because as a topical route of administration gloves can reduce inadvertent absorption through the hands. The medication will be absorbed through the skin so there is no need to remove the previous dose and reapply, avoid taking baths or showers, or cover with gauze.

A client's record can be more accurate if the nurse:

Uses point-of-care documentation -Point-of-care documentation takes place as care occurs, thus enhancing accuracy. Today many facilities incorporate technology that is mobile and can be used immediately at the client's bedside for point-of-care documentation.

In the provision of care and the establishment of the therapeutic relationship, the nurse must first:

be aware of one's own personality -Before a nurse can communicate therapeutically, a comfortable sense of self, such as being aware of one's own personality, values, cultural background, and style of communication, is necessary.

A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from:

congestive heart failure. -A client who has edema and a cough that is productive with frothy sputum is manifesting heart failure.

The client sustained a large skin tear to his arm while getting out of bed. He is concerned that it is now infected. Which manifestation shows infection?

enlarged axillary lymph nodes -During an infection, the lymph nodes that drain an infected area may become enlarged and easily palpable ("swollen glands"). As the swelling increases, the nodes may also become tender. During inflammation, the lymphatic capillaries dilate as excess interstitial fluid, proteins, and invading microorganisms enter the lymphatic system. The swelling indicates that lymphocytes and macrophages in the lymph node are fighting the infection and trying to limit its spread.

A 70-year-old client with chronic obstructive pulmonary disease (COPD) has a respiratory infection being treated with antibiotics. He is also taking oral corticosteroids to assist in decreasing the inflammation in the lungs. The client is prone to:

superinfection - Drug therapy can cause defects in the host's response to infection. Steroids, chemotherapy, antimetabolites, and inappropriate or prolonged use of antibiotics can increase the risk of infection.

A nurse suctioning a client through a tracheostomy tube should be careful not to occlude the Y-port when inserting the suction catheter because it would cause what condition to occur?

trauma to the tracheal mucosa -Occluding the Y-port on the suction tubing is what creates the suction. While suctioning would be difficult but possible, suctioning while advancing the tube would damage the tracheal mucosa and remove excessive amounts of oxygen, not carbon dioxide, from the respiratory tract. Suctioning during insertion of the catheter would not compromise sterility.