Nursing Fundamentals Practice Questions, Nursing Fundamentals Practice Final Exam, Hesi Fundamentals 2 Practice Questions, Fundamentals For Nursing Edition 9.0 Practice Questions, Fundamental HESI, Hesi Fundamentals, Hesi Fundamentals Practice Test,...
Which of the following is correctly stated nursing diagnosis? a. needs to be fed related to broken right arm b. impaired skin integrity related to fecal incontinence c. abnormal breath sounds caused by weak cough reflex d. impaired physical mobility related to RA
Answer: b. impaired skin integrity related to fecal incontinence Rationale: it is the patient's actual or potential response to the health problem
A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 Normal Saline with Potassium Chloride 20mRq at 83 ml/hr. Client's 8 hour urine output is 400 ml, BUN 15mg/dl, lungs are clear bilaterally, serum glucose is 120 mg/dl and the serum potassium is 3.7 mEq/l. Which action is most important?
Answer: c. document in medical record that these normal findings are expected outcomes Rationale: all results are within normal range
Rate is verrrry fast Defib, acls, amiodarone
Vfib
prime duty of a nurse
prime duty for the nurse is to protect clients from harm to keep clients safe
protocol for droplet precautions
private room / cohort mask
An IV infusion terbutaline sulfate 5 mg in 500 ml of D5W, is infusing at a rate of 30 mcg/min prescribed for a client in premature labor. How many ml/hr should the nurse set the infusion pump? A. 30 B. 60 C. 120 D. 180
(D) is correct calculation: 180 ml/hr = 500 ml/5 mg × 1mg/1000 mcg × 30 mcg/min × 60 min/hr. Correct Answer: D
Which of the following are cues rather than inferences? Select all that apply. 1) Ate 50% of his meal 2) Patient is depressed today 3) States "I slept well today" 4) White blood cell count 15000/mm
1) Ate 50% of his meal 3) States "I slept well today" 4) White blood cell count 15000/mm Patient is depressed today is an inference.
Which body fluid lies in the spaces between the body cells? 1) interstitial 2) intracellular 3) intravascular 4) transcellular
1) interstitial
an adult needs ____ ml of fluid daily to prevent hardening of stool
1,400-2,000
What are the professional values of a nurse?
1. Altruism 2. Autonomy 3. Human dignity 4. Integrity 5. Social justice
What are the roles of a nurse?
1. Caregiver 2. Communicator 3. Educator 4. Counselor 5. Leader 6: Researcher 7. Advocate 8. Collaborator
What are the four elements of liability?
1. Duty. 2. Breach of Duty. 3. Causation 4. Damages.
What are the 6 QSEN competencies?
1. Patient-centered care 2. Teamwork and collaboration 3. Quality improvement 4. Safety 5. Evidence-based practice 6. Informatics
What are the FOUR aims of nursing?
1. To promote health. 2. To prevent illness. 3. To restore health (alleviate suffering). 4. To facilitate coping with disability or death.
What are the four blended competencies of nursing?
1. cognitive 2. technical 3. interpersonal 4. ethical/legal
specific gravity of urine
1.003-1.030
A nurse is preparing to administer dextrose 5% in water (D5W) 1000 mL IV to infuse over 10 hr. The nurse should set the IV infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Do not use a trailing zero.)
100 mL/hr
identity vs role confusion
12 to 18
The tiny air sacs that compose the lungs and are the site of gas exchange are known as which of the following? 1) Bronchi 2) Alveoli 3) Cilia 4) Hypoxemia
2) Alveoli
Rhumeatoid arthritis meds may take _____ to be effective?
2-4 weeks
initiative vs guilt
3 TO 5
What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply. 1 Tetany 2 Seizures 3 Diarrhea 4 Weakness 5 Dysrhythmias
3,4,5 Tetany is caused by hypocalcemia. Seizures caused by electrolyte imbalances are associated with low calcium or sodium levels. Because of potassium's role in the sodium/potassium pump, hyperkalemia will cause diarrhea, weakness, and cardiac dysrhythmias.
pH of urine
4.5-7.8
generatvitiy vs stagnation
40 to 65
A nurse is preparing to administer lactated Ringer's (LR) IV 100 mL over 15 min. The nurse should set the IV infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Do not use a trailing zero).
400 mL/hr
normal WBC count
5,000-10,000
point of maximum impulse
5th intercostal space
Below are the top six causes of accidental death. Put them in the correct order, from the most prevalent cause to the least prevalent cause of the six. 1. Fires 2. Falls 3. Motor vehicle accidents 4. Drowning 5. Firearms 6. Poisoning
6. Poisoning 3. Motor vehicle accidents 5. Firearms 2. Falls 4. Drowning 1. Fires
A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump?
63 ml/hour.
A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client A. asks relevant questions regarding the dressing change. B. states he will be able to complete the wound care regimen. C. demonstrates the wound care procedure correctly. D. has all the necessary supplies for wound care.
A return demonstration of a procedure (C) provides an objective assessment of the client's ability to perform a task, while (A and B) are subjective measures. (D) is important, but is less of a priority prior to discharge than the nurse's assessment of the client's ability to complete the wound care. Correct Answer: C
89.What action is most important for the nurse to implement when placing a client in the Sim's position? A. Raise the bed to a waist-high working level. B. Elevate the head of the bed 45 degrees. C. Place a pillow behind the client's back. D. Bring the client to one edge of the bed.
A waist-high bed height (A) is a comfortable and safe working height to maintain the nurse's proper body mechanics and prevent back injury. The head should be flat for a Sim's side-lying position, not raised (B). (C) is implemented after the client is positioned laterally. (D) brings the client closer to the nurse when being turned. Correct Answer: A
In infectious diseases such as hepatitis B and C, a reservoir for pathogens is: A) The blood B) The urinary tract C) The respiratory tract D) The reproductive tract
A) The blood The blood is a reservoir for pathogens in hepatitis B and C. Neither organism can survive in the urinary, reproductive, or respiratory tract
A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? Select all that apply. a. Hold the cane on the right side b. Keep two points of support on the floor c. Place the cane 38 cm (15 in) in front of the fee before advancing d. After advancing the cane, move the weaker leg forward e. Advance the stronger leg so that it aligns evenly with the cane
A, B, D
It would be appropriate to delegate the taking of vital signs of which of the following clients to a UAP? A. A client being prepared for elective facial surgery with a hx of stable hypertension B. A client receiving a blood transfusion with a history of transfusion reactions C. A client recently started on a new antiarrhythmic agent D. A client who is admitted frequently with asthma attacks
A. A client being prepared for elective facial surgery with a hx of stable hypertension Feedback Vital signs may be delegated if they are stable, the findings are expected or the technique requires no modification.
Leininger's theory of cultural care diversity and universality specifically addresses: A) Caring for clients from unique cultures B) Understanding the humanistic aspects of life C) Identifying variables affecting a client's response to a stressor D) Caring for clients who cannot adapt to internal and external environmental demands
A. Caring for clietns from unique cultures The goal of Leininger's theory is to provide the client with culturally specific nursing care, in which the nurse integrates the client's cultural traditions, values, and beliefs into the plan of care.
While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement?
Acknowledge that she is supporting the arm correctly.
During a physical assessment, a female client begins to cry. Which action is best for the nurse to take?
Acknowledge the client's distress and tell her it is all right to cry.
In a nutshell, the ICN's key values of nursing are:
Advocacy, promotion of a safe environment, research, education, and participation in shaping health policy and in patient and health systems management.
Serum Potassium
After being sick for 3 days, a client with a history of diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). The nurse should evaluate which diagnostic test results to prevent arrhythmias?
ANA =
American Nursing Association
Deontologic =
An action is right or wrong independent of its consequences.
Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5.5 hours. How much heparin has the client received? a. 11,000 units b. 13,000 units c. 15,000 units d. 17,000 units
Answer: a. 11,000 units Rationale: 50 x 5.5 = 275 ml 20,000 units / 500 ml = 40 units / ml 275 x 40 = 11,000
Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention?
Assess for bladder distention.
The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan?
Avoid any types of sprays, powders, and perfumes.
Nonmaleficence =
Avoid causing harm
Patient taking Digoxin
Avoid concurrent use of herbals
Seconal 0.1 gram PRN at bedtime is prescribed to a client for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer? A) 0.5 tablet. B) 1 tablet. C) 1.5 tablets. D) 2 tablets.
B) 1 tablet 15 gr=1 Gm. Converting the prescribed dose of 0.1 grams to grains requires multiplying 0.1 × 15 = 1.5 grains. The tablets come in 1.5 grains, so the nurse should plan to administer 1 tablet (B).
Facial spasm after tapping facial nerve and seen in patients with hypocalcemia
Chvostek's sign
Patient in ventricular fibrillation
Defib shock once
Symptoms + BG >=200ml/dl at any time w/o regard to meal 2hr post-load glucose >200 (oral gluc test) fasting >126
Diagnostic Criteria
client experiencing intracranial HTN from traumatic brain injury, admitted to trauma unit. How should the nurse position him?
Elevated HOB
During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement?
Encourage additional oral intake of juices and water
Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube?
Examining a chest x-ray obtained after the tubing was inserted.
Who is the founder behind the profession of nursing?
Florence Nightingale
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care?
Gently lift the client when moving into a desired position.
subset of type 2 due to hormone release from placenta resist insulin 2nd & 3rd Trimester, give glucose challenge, dx if over 126
Gestational Diabetes
Chest tube becomes disconnected
Get new saline bottle to stick end into until reconnect tube
Justice =
Give each his or her due and act fairly
When to use? Morphine, O2, nitroglycerin, aspirin
MONA
Nursing is . . . .
NOTHING without critical thinking!
NGT irrigation
NURSE not UNP
What is unintentional torts?
Negligence & Malpractice
UAP giving complete bath-which patient is more of a concern
Patient with dyspnea (SOB when lying flat)
One can practice reflective practice in many different ways . . .
Reflection *IN* action (present) Reflection *ON* action (past) Reflection *FOR* action (future)
A client has a prescription for azithromycin 500mg diluted in 250ml of NS IV q24h for 3 doses. What action should the nurse implement?
Set the does times for q8h
Regular(Humalin), Semilente Onset: 1-1.5 hr Duration: 4-6 hours Peak: 2-3 hours
Short Acting
Autonomy =
Standing alone; independence; right to self-determination
Advocacy =
Standing up for someone, other than oneself, when they are unable, or not prepared, to make a decision, or action, for themselves.
16. A review of systems (ROS) is based on information obtained from the client during the interview. This information is an example of ______________ data.
Subjective
Vagus stimulate, adenisone, cardiovert Narrow QRS
Svt
The T wave depicts the relative refractory period, representing ventricular repolarization
T Wave
Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse?
The body's receptors adapt over time as they are exposed to heat.
The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility?
The client voluntarily signed the form.
What is the purpose of HIPAA?
To ensure patient rights.
Prior to transferring a client to a chair using a mechanical lift, what is the most important client characteristic to assess?
Tolerance of exertion
What's a crime?
Wrong against person/property & the public
Goal
a broad statement that describes a desired change in a patient's condition over time
most at risk for developing DVT
a fractured hip
Identify the variety of sources where data can be obtained (a-e)
a. the patient through interviews, observations, and physical exam b. family members or significant others c. other members of the health team d. medical record e. scientific and medical literature
locate the fundus on diagram
above umbilicus
z track
after needle is withdrawn from the skin surface is when nurse should release the retracted tissue OR understand the reason for z track method is to prevent leakage
man with asthma is brought to the ED by automobile. He is SOB and appears frightened
anxiety
nurse can't delegate
anything that requires nursing judgment, skill, or knowledge
patient being discharged after being treated for epistaxis
apply ice compresses to the nose pinch the entire soft lower portion of the nose partially insert a small gauze pad into the bleeding nostril
hypoxia signs / symptoms
apprehension, anxiety, behavioral changes, decreased LOC, confusion, increased pulse, dyspnea, use of accessory muscles of respiration, rib, retractions , clubbing of nails
cardiac output calculation
cardiac output = heart rate x stroke volume
Reasons for seeking health care
chief concerns or problems
Early morning hyperglycemia resulting from increased growth hormone circulation
dawn phenomenon
test result indicative to patient responding to asthma attack meds
decreased exhaled nitric oxide
nurse plans frequent monitoring of the skin color, mucus membranes, nail beds of client with ARF. What is the purpose?
detect signs of enemia
continue to monitor the client without infusing any solution through the PEG tube
feeding supplements are typically initiated when bowel sounds are present, usually within 24 hours after PEG tube insertion
russel traction
femur or lower leg instability
nurse overhears two employees discussing confidential patient information in the cafeteria. Breach of which ethical principle?
fidelity
Nursing Process
five-step clinical decision making approach
temp conversion
from celsius to farenheit f=c+40 multiply times (9/5) subtract 40 c = f + 40 x (5/9) subtract 40
barrier precautions
include gown, gloves, eyewear,
chemotherapy - thrombocytopenia
increased risk for bleeding, bleeding precautions
orthostatic vital signs
lying, sitting, standing
reservior
natural habitat of organisms
45 year old female with a pulmonary embolism
obestiy hypertension cigarette smoking recent long distance travel
when patient is most infectious
prodormal
changing the wound dressing - it smells and a lot of puss
re-dress the wound, using strict aspesis, and notify HCP
sacral area reddened for 2 hours non blanchabele
reactive hyperemia
Thinking Independently
read the nursing literature
Humilty
recognize when you need more information to make a decision
Psychosocial history
reveals the patient's support systems and coping mechanisms
Autonomy
rights to give informed consent is based on this principle
drainage
serous clear watery plasma purulent thick yellow, green, tan, brown serosanguineous pale red water sanguineous: bright red indicates active bleeding
Nursing is a profession dedicated to . . .
serving others.
Values =
shape our choices, behavior, and identity
assess length of wound tract
sterile cotton tipped applicatior
stoma assessment
stoma will shrink within 6 to 8 weeks after surgery, therefore it needs to be measured at least once weekly during this time as needed if the patient gains or loses weight. A healthy stoma should be reddish pink and moist and protrude
atelectasis
tachycardia, asymmetrical chest movements, and decreased breath sounds
repeat 99
tactile fremitus
patient is having dyspnea what would the nurse do first
take the blood pressure
Discipline
take time to be thorough and manage your time effectively
gerd interventions
teach client to eliminate foods that decrease LES like chocolate, alcohol, fatty foods, and carbonated beverages. The patient should also restrict spicy and acidic foods
Defining characteristics
the clinical criteria or assessment findings that support an actual nursing diagnosis
ABG lab test performed to determine
the efficiency of respiratory ventilation
Family history
to determine whether patient is at risk for illnesses of a genetic or familial nature
stage 1 dressing
transparent film dressing
Erikson
trust vs mistrust infancy to 1 1/2
Pressure ulcer
turning the patient and noticing no pressure, redness, and patient does not complain of pain
four ways of obtaining temperature
tympanic, rectal, oral, axillary
Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent?
upper arm circumference
pediculosis capitis
use fine toothed comb, don't cut hair, white matter to the hair
patient with an acute exacerbation of asthma
wheezing becomes louder
hematuria assess blood in the urine
when starting the urine stream or at the end of voiding
An older female is admitted for 24 hours to the hospital for observation, what should the nurse report to the dr?
widening pulse pressure with an increase in pulse rate
diagnosis of activity intolerance for a patient with asthma
work of breathing
Nursing . . .
predates written history.
systolic
pressure when the heart is contracting
assisting patient to cough effectively:
increase fluids to loosen secretions
PASS
pull aim squeeze sweep
to determine presence of fecal impaction select all
radiographic examination digital rectal examination
Nursing care plan
should direct clinical nursing care and decrease the risk of incomplete, incorrect, or inaccurate care. It identifies and coordinates resources for delivering care. It lists the interventions needed to achieve the goals of care
Seconal 150mg is prescribed at bedtime for a male client who is scheduled for surgery in the morning. The scored tablets are labeled 0.1g/tablet. How many tablets should the nurse administer?
0.1 g = 100 mg 100 x 1.5 = 150 mg Answer: 1. 5 tabs
You are caring for a client who has been confined to bed for several weeks. Which of the following are effects of immobility that you should assess for and address in this client? SELECT ALL THAT APPLY. 1) Contractures 2) Hypertrophy 3) Ankylosis 4) Tremor 5) Atrophy 6) Osteoporosis
1) Contractures 3) Ankylosis 5) Atrophy 6) Osteoporosis
Physiological changes associated with aging place the older adult at risk for which nursing diagnosis? 1) Risk for falls 2) Risk for ineffective airway clearance 3) Risk for poisoning 4) Risk for suffocation
1) Risk for falls Loss of muscle strength and joint mobility place the older adult at risk for falls
leading dose
a large first dose, is often used used to achieve a therapeutic level more rapidly in the bloodstream
Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? A. 11,000 units. B. 13,000 units. C. 15,000 units. D. 17,000 units.
(A) is the correct calculation: 20,000 units/500 ml = 40 units (the amount of units in one ml of fluid). 40 units/ml x 50 ml/hr = 2,000 units/hour (1,000 units in 1/2 hour). 5.5 x 2,000 = 11,000 (A). OR, multiply 5 x 2,000 and add the 1/2 hour amount of 1,000 to reach the same conclusion = 11,000 units. Correct Answer: A
An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L. Which disturbance should the nurse identify based on these results? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis A low pH and low bicarbonate level are consistent with metabolic acidosis. The pH indicates acidosis. The CO2 concentration is within normal limits, which is inconsistent with respiratory acidosis; it is elevated with respiratory acidosis.
1 A low pH and low bicarbonate level are consistent with metabolic acidosis. The pH indicates acidosis. The CO2 concentration is within normal limits, which is inconsistent with respiratory acidosis; it is elevated with respiratory acidosis. Ph-7.35-7.45 PCO2 - 35-45 HCO3 - 22-30
What type of interview is most appropriate when a nurse admits a client to a clinic? 1 Directive 2 Exploratory 3 Problem solving 4 Information giving
1 The first step in the problem-solving process is data collection so that client needs can be identified. During the initial interview a direct approach obtains specific information, such as allergies, current medications, and health history. The exploratory approach is too broad because in a nondirective interview the client controls the subject matter. Problem solving and information giving are premature at the initial visit.
A nurse is caring for an older adult who is taking acetaminophen (Tylenol) for the relief of chronic pain. Which substance is most important for the nurse to determine if the client is taking because it intensifies the most serious adverse effect of acetaminophen? 1 Alcohol 2 Caffeine 3 Saw palmetto 4 St. John's wort
1 Too much ingestion of alcohol can cause scarring and fibrosis of the liver. Eighty-five to 95% of acetaminophen is metabolized by the liver. Acetaminophen and alcohol are both hepatotoxic substances. Metabolites of acetaminophen along with alcohol can cause irreversible liver damage. Caffeine affects (stimulates) the cardiovascular system, not the liver. In addition, caffeine does not interact with acetaminophen. Saw palmetto is not associated with increased liver damage when taking acetaminophen. It often is taken for benign prostatic hypertrophy because of its antiinflammatory and antiproliferative properties in prostate tissue. St. John's wort is classified as an antidepressant and is not associated with increased liver damage when taking acetaminophen. However, it does decrease the effectiveness of acetaminophen.
Twenty-four hours after a cesarean birth, a client elects to sign herself and her baby out of the hospital. Staff members are unable to contact her health care provider. The client arrives at the nursery and asks that her infant be given to her to take home. What is the most appropriate nursing action? 1 Give the infant to the client and instruct her regarding the infant's care. 2 Explain to the client that she can leave, but her infant must remain in the hospital. 3 Emphasize to the client that the infant is a minor and legally must remain until prescriptions are received. 4 Tell the client that hospital policy prevents the staff from releasing the infant until ready for discharge
1 When a client signs herself and her infant out of the hospital, she is legally responsible for her infant. The infant is the responsibility of the mother and can leave with the mother when she signs them out.
autonomy vs shame
1 2/2 to 3
Parents of a child with cystic fibrosis ask about their chances of having another cystic fibrosis child?
1 in 4 chance
Seconal 0.1 gram PRN at bedtime is prescribed to a client for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer?
1 tab
You are preparing to use the Morse fall scale to assess a client's risk for falls. Which of the following factors does this scale assess for in the client? SELECT ALL THAT APPLY. 1) History of falling 2) Age 3) Gender4) Presence of more than one medical diagnosis 5) Use of ambulatory aids 6) Mental status
1) History of falling 4) Presence of more than one medical diagnosis 5) Use of ambulatory aids 6) Mental status
The nursing instructor asks students how they would assess the 5th vital sign. Which student would be correct? 1) I would ask the patient what their pain was on a scale of 0-10 2) I would ask the patient when they last had a bowel movement 3) I would check the patient's respiratory rate 4) I would ask the patient about their tobacco use.
1) I would ask the patient what their pain was on a scale of 0-10
A patient with Parkinson's Disease is at risk for which complication? 1) Impaired kinesthesia 2) macular degeneration 3) seizures 4) Xerostomia
1) Impaired Kinesthesia
A client is receiving albuterol (Proventil) to relieve severe asthma. For which clinical indicators should the nurse monitor the client? Select all that apply. 1 Tremors 2 Lethargy 3 Palpitations 4 Visual disturbances 5 Decreased pulse rate
1,3 Albuterol's sympathomimetic effect causes central nervous stimulation, precipitating tremors, restlessness, and anxiety. Albuterol's sympathomimetic effect causes cardiac stimulation that may result in tachycardia and palpitations. Albuterol may cause restlessness, irritability, and tremors, not lethargy. Albuterol may cause dizziness, not visual disturbances. Albuterol will cause tachycardia, not bradycardia.
A nurse is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure? Select all that apply. 1 Clean the eyelid and eyelashes. 2 Place the dropper against the eyelid. 3 Apply clean gloves before beginning of procedure. 4 Instill the solution directly onto cornea. 5 Press on the nasolacrimal duct after instilling the solution.
1,3,5 Cleaning of the eyelids and eyelashes helps to prevent contamination of the other eye and lacrimal duct. Application of gloves helps to prevent direct contact of the nurse with the client's body fluids. Applying pressure to the nasolacrimal duct prevents the medication from running out of the eye. The dropper should not touch the eyelids or eyelashes in order to prevent contamination of the medication in the dropper. The medication should not be instilled directly onto the cornea because cornea has many pain fibers and is therefore very sensitive. The medication is to be instilled into the lower conjunctival sac.
The nurse manager is planning to assign an unlicensed assistive personnel (UAP) to care for clients. What care can be delegated on a medical-surgical unit to a UAP? Select all that apply. Correct 1 Performing a bed bath for a client on bed rest 2 Evaluating the effectiveness of acetaminophen and codeine (Tylenol #3) 3 Obtaining an apical pulse rate before oral digoxin (Lanoxin) is administered Correct 4 Assisting a client who has patient-controlled analgesia (PCA) to the bathroom 5 Assessing the wound integrity of a client recovering from an abdominal laparotomy
1,4 Performing a bed bath for a client on bed rest is within the scope of practice of the UAP. Assisting a client who has PCA to the bathroom does not require professional nursing judgment and is within the job description of the UAP. Evaluating human responses to medications requires the expertise of a licensed professional nurse. Obtaining an apical pulse rate requires a professional nursing judgment to determine whether or not the medication should be administered. Evaluating human responses to health care interventions requires the expertise of a licensed professional nurse.
A patient who underwent a left above the knee amputation complains of pain in his left foot. What type of pain is he experiencing? 1) psychogenic 2) phantom 3) reffered 4) radiating
2) phantom
A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the secondary infusion?
150
Atropine Conduction is slow, rate can be normal
1st degree av block
The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to
1½ tablets
The nurse notes that an advance directive is on a patient's medical record. Which statement represents the best description of an advance directive guideline the nurse will follow? [23] 1. A living will allows an appointed person to make health care decisions when the patient is in an incapacitated state. 2. A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state. 3. The patient can not make changes in the advance directive once admitted to the hospital. 4. A durable power of attorney for health care is invoked only when the patient has a terminal condition or is in a persistent vegetative state.
2
The nurse receives an order to start giving a loop diuretic to a patient to help lower his or her blood pressure. The nurse determines that the appropriate route for administering the diuretic according to: [31] 1. Hospital policy 2. The prescriber's orders 3. The type of medication ordered 4. The patient's size and muscle mass
2
During the initial physical assessment of a newly admitted client with a pressure ulcer, a nurse observes that the client's skin is dry and scaly. The nurse applies emollients and reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate? 1 The nurse also should have instituted a plan to increase activity. 2 The nurse provided supportive nursing care for the well-being of the client. 3 Debridement of the pressure ulcer should have been done before the dressing was applied. 4 Treatment should not have been instituted until the health care provider's prescriptions were received.
2 According to the Nurse Practice Act, a nurse may independently treat human responses to actual or potential health problems. An activity level is prescribed by a health care provider; this is a dependent function of the nurse. There is not enough information to come to the conclusion that debridement should have been done before the dressing was applied. Application of an emollient and reinforcing a dressing are independent nursing functions.
Which of the following outcome statements for the goal, "Patient will achieve a gain of 10 lbs (4.5 kg) in body weight in a month" are worded incorrectly? (Select all that apply) [18] 1. Patient will eat at least three fourths of each meal by 1 week 2. Patient will verbalize relief of nausea and have no episodes of vomiting in 1 week 3. Patient will eat foods with high-calorie content by 1 week 4. Give patient liquid supplements 3 time a day
2, 4
A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order. [16] 1. "You say you've lost weight. Tell me how much weight you have lost in the past month." 2. "My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history." 3. "I have no further questions. That you for your patience." 4. "Tell me what brought you to the hospital." 5. "So, to summarize, you've lost about 6 pounds in the last month, and your appetite has been poor - correct?"
2, 4, 1, 5, 3
Insulin can be kept at room temperature for
28 days
Which outcome allows you to measure a patient's response to care more precisely? [18] 1. The patient's wound will appear normal within 3 days 2. The patient's wound will have less drainage within 72 hours 3. The patient's wound will reduce in size to less than 4 cm (1 1/2 inches) by day 4. 4. The patient's wound will heal without redness or drainage by day 4.
3
While preparing to do a sterile dressing change, a nurse accidentally sneezes over the sterile field that is on the over-the-bed table. Which of the following principles of surgical asepsis, if any, has been violated? [28] 1. When a sterile field comes in contact with a wet surface, the sterile field is contaminated by capillary action 2. Fluid flows in the direction of gravity 3. A sterile field becomes contaminated by prolonged exposure to air 4. None of the principles were violated
3
You are the night shift nurse and are caring for a newly admitted patient who appears confused. The family asks to see the patient's medical record. What is the first nursing action to take? [23] 1. Give the family the record 2. Give the patient the record 3. Discuss the issues that concern the family with them 4. Call the nursing supervisor
3
A client comes to the clinic complaining of a productive cough with copious yellow sputum, fever, and chills for the past two days. The first thing the nurse should do when caring for this client is to: 1 Encourage fluids. 2 Administer oxygen. 3 Take the temperature. 4 Collect a sputum specimen
3 Baseline vital signs are extremely important; physical assessment precedes diagnostic measures and intervention. This is done after the health care provider makes a medical diagnosis; this is not an independent function of the nurse. Encouraging fluids might be done after it is determined whether a specimen for blood gases is needed; this is not usually an independent function of the nurse. Oxygen is administered independently by the nurse only in an emergency situation. A sputum specimen should be obtained after vital signs and before administration of antibiotics.
The nurse should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may: 1 Force urine to back up into the kidneys. 2 Suppress production of urine. 3 Cause the device to pull away from the skin. 4 Tear the ileal conduit
3 If the device becomes full and is not emptied, it may pull away from the skin and leak urine. Urine in contact with unprotected skin will irritate and cause skin breakdown. A full urine collection bag will not cause urine to back up into the kidneys, suppress the production of urine, or tear the ileal conduit.
What is a basic concept associated with rehabilitation that the nurse should consider when formulating discharge plans for clients? 1 Rehabilitation needs are met best by the client's family and community resources. Incorrect2 Rehabilitation is a specialty area with unique methods for meeting clients' needs. Correct3 Immediate or potential rehabilitation needs are exhibited by clients with health problems. 4 Clients who are returning to their usual activities following hospitalization do not require rehabilitation.
3 Rehabilitation refers to a process that assists clients to obtain optimal functioning. Care should be initiated immediately when a health problem exists to avoid complications and facilitate recuperation. All resources that can be beneficial to client rehabilitation, including the private health care provider and acute care facilities, should be used. Rehabilitation is a commonality in all areas of nursing practice. Rehabilitation is necessary to help clients return to a previous or optimal level of functioning.
A nurse discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a history of alcoholism. What need must self-help groups such as AA meet to be successful? 1 Trust 2 Growth 3 Belonging 4 Independence
3 Self-help groups are successful because they support a basic human need for acceptance. A feeling of comfort and safety and a sense of belonging may be achieved in a nonjudgmental, supportive, sharing experience with others. AA meets dependency needs rather than focusing on independence, trust, and growth.
A nurse receives a subpoena in a court case involving a child. The nurse is preparing to appear in court. In addition to the state Nurse Practice Act and the American Nursing Association (ANA) Code for Nurses, what else should the nurse review? 1 Nursing's Social Policy Statement 2 State law regarding protection of minors 3 ANA Standards of Clinical Nursing Practice 4 References regarding a child's right to consent
3 The ANA Standards of Clinical Nursing Practice guidelines govern safe nursing practice; nurses are legally responsible to perform according to these guidelines. Nursing's Social Policy Statement explains what the public can expect from nurses, but it is not used to govern nursing practice. There are no data that indicate state law regarding protection of minors and references regarding a child's right to consent are necessary.
A nurse cares for a client that has been bitten by a large dog. A bite by a large dog can cause which type of trauma? 1 Abrasion 2 Fracture 3 Crush injury 4 Incisional laceration
3 The bite of a large dog can exert between 150 and 400 psi of pressure, causing a crush injury. A crush injury may or may not include a fracture. Abrasions and incisional lacerations are not caused by this form of trauma.
A client has undergone a subtotal thyroidectomy. The client is being transferred from the post anesthesia care unit/recovery area to the inpatient nursing unit. What emergency equipment is most important for the nurse to have available for this client? 1 A defibrillator 2 An IV infusion pump 3 A tracheostomy tray 4 An electrocardiogram (ECG) monitor
3 The client who has undergone a subtotal thyroidectomy is at high risk for airway occlusion resulting from postoperative edema. With this in mind, emergency airway equipment such as a tracheostomy set and intubation supplies should be immediately available to the client. A defibrillator, an IV infusion pump, and an electrocardiogram (ECG) monitor are all equipment items that should be available to all postoperative clients.
During the review of systems in a nursing history, a nurse learns that the patient has been coughing mucus. Which of the following nursing assessments would be best for the nurse to use to confirm a lung problem? (Select all that apply) [16] 1. Family report 2. Chest x-ray film 3. Physical examination with auscultation of the lungs 4. Medical record summary of x-ray film findings
3, 4
What type of interview techiniques does the nurse use when asking these questions, "Do you have pain or cramping?" "Does the pain get worse when you walk?" (Select all that apply) [16] 1. Active listening 2. Open-ended questioning 3. Closed-ended questioning 4. Problem-oriented listening
3, 4
A client receiving steroid therapy states, "I have difficulty controlling my temper which is so unlike me, and I don't know why this is happening." What is the nurse's best response? 1 Tell the client it is nothing to worry about. 2 Talk with the client further to identify the specific cause of the problem. 3 Instruct the client to attempt to avoid situations that cause irritation. 4 Interview the client to determine whether other mood swings are being experienced.
4
The evaluation process includes interpretation of findings as one of its five elements. Which of the following is an example of interpretation? [20] 1. Evaluating the patient's response to selected nursing interventions 2. Selecting an observable or measurable state or behavior that reflects goal achievement 3. Reviewing the patient's nursing diagnoses and establishing goals and outcome statements 4. Matching the results of evaluative measures with expected outcomes to determine patient's status
4
The nurse is assessing the character of a patient's migraine headache and asks, "Do you feel nauseated when you have a headache?" The patient's response is "yes." In this case, the finding of nausea is which of the following? [16] 1. An objective finding 2. A clinical inference 3. A validation 4. A concomitant symptom
4
A client has been diagnosed as brain dead. The nurse understands that this means that the client has: 1 No spontaneous reflexes 2 Shallow and slow breathing 3 No cortical functioning with some reflex breathing 4 Deep tendon reflexes only and no independent breathing
4 A client who is declared as being brain dead has no function of the cerebral cortex and a flat EEG. The client may have some spontaneous breathing and a heartbeat. The guidelines established by the American Association of Neurology include coma or unresponsiveness, absence of brainstem reflexes, and apnea. There are specific assessments to validate the findings. The other answer options do not fit the definition of brain dead.
When being interviewed for a position as a registered professional nurse, the applicant is asked to identify an example of an intentional tort. What is the appropriate response? 1 Negligence 2 Malpractice 3 Breach of duty 4 False imprisonment
4 False imprisonment is a wrong committed by one person against another in a willful, intentional way without just cause or excuse. Negligence is an unintentional tort. Malpractice, which is professional negligence, is classified as an unintentional tort. Breach of duty is an unintentional tort.
A client who was exposed to hepatitis A asks why an injection of gamma globulin is needed. Before responding, what should the nurse consider about how gamma globulin provides passive immunity? 1 It increases production of short-lived antibodies. 2 It accelerates antigen-antibody union at the hepatic sites. 3 The lymphatic system is stimulated to produce antibodies. 4 The antigen is neutralized by the antibodies that it supplies
4 Gamma globulin, which is an immune globulin, contains most of the antibodies circulating in the blood. When injected into an individual, it prevents a specific antigen from entering a host cell. Gamma globulin does not stimulate antibody production. It does not affect antigen-antibody function.
Often when a family member is dying, the client and the family are at different stages of grieving. During which stage of a client's grieving is the family likely to require more emotional nursing care than the client? 1 Anger 2 Denial 3 Depression 4 Acceptance
4 In the stage of acceptance, the client frequently detaches from the environment and may become indifferent to family members. In addition, the family may take longer to accept the inevitable death than does the client. Although the family may not understand the anger, dealing with the resultant behavior may serve as a diversion. Denial often is exhibited by the client and family members at the same time. During depression, the family often is able to offer emotional support, which meets their needs.
A postoperative client says to the nurse, "My neighbor, I mean the person in the next room, sings all night and keeps me awake." The neighboring client has dementia and is awaiting transfer to a nursing home. How can the nurse best handle this situation? 1 Tell the neighboring client to stop singing. 2 Close the doors to both clients' rooms at night. 3 Give the complaining client the prescribed as needed sedative. 4 Move the neighboring client to a room at the end of the hall
4 Moving the client who is singing away from the other clients diminishes the disturbance. A client with dementia will not remember instructions. It is unsafe to close the doors of clients' rooms because they need to be monitored. The use of a sedative should not be the initial intervention
A nurse assesses a client's serum electrolyte levels in the laboratory report. What electrolyte in intracellular fluid should the nurse consider most important? 1 Sodium 2 Calcium 3 Chloride 4 Potassium
4 The concentration of potassium is greater inside the cell and is important in establishing a membrane potential, a critical factor in the cell's ability to function. Sodium is the most abundant cation of the extracellular compartment, not the intracellular compartment. Calcium is the most abundant electrolyte in the body; 99% is concentrated in the teeth and bones, and only 1% is available for bodily functions. Chloride is an extracellular, not intracellular, anion.
What's a tort?
A wrong committed by a person against another person or property; tried in civil court.
The nurse delegates to an unlicensed assistant the task of removing the restraints from the client's wrists every ________ hours and reporting any abnormalities. A) 2 B) 4 C) 6 D) 8
A) 2 Removal of restraints and inspection of the contact area every 2 hours is a requirement of The Joint Commission. The time periods in the other options are too long. The client could experience a serious complication if restraints are not removed and the area under the restraints inspected frequently.
When a nurse is performing surgical hand hygiene, the nurse must keep the hands: A) Above the elbows B) Below the elbows C) At a 45-degree angle D) In a comfortable position
A) Above the elbows When surgical hand hygiene is performed, the hands should always be kept above the elbows so that the water runs from the hands to the elbows.
A client comes to the walk-in clinic with reports of abdominal pain and diarrhea. While taking the client's vital signs, the nurse is implementing which phase of the nursing process? A. Assessment B. Diagnosis C. Planning D. Implementation
A. Assessment Rationale: The first step in the nursing process is assessment, the process of collecting data. All subsequent phases of the nursing process (options 2, 3, and 4) rely on accurate and complete data.
Environmental factors heavily affect a client's care. Your first concern for the client includes which of the following? A) Safety B) Nurse staffing C) Confidentiality D) Adequate pain relief
A. Safety Client safety is an environmental factor and is always the first concern. Pain relief, staffing, and confidentiality are important but are not environmental factors.
What are the steps of the nursing process?
ASSESS DIAGNOSE PLAN IMPLEMENT EVALUATE -DOCUMENT-
The nurse plans a teaching session with a client but postpones the planned session based on which nursing diagnosis?
Activity intolerance related to postoperative pain
A nurse is reviewing documentation with a group of newly license nurses. Which of the following legal guidelines should be followed when documenting in a client's record? Select all that apply a. Cover errors with correction fluid, and write in the correct information b. Put the date and time on all entries c. Document objective data, leaving out opinions d. Use as many abbreviations as possible e. Wait until the end of the shift to document
B, C
The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min? A) 42 gtt/min. B) 83 gtt/min. C) 125 gtt/min. D) 250 gtt/min
B. 83 gtt/min
When teaching older adults, the nurse should: A) Speak in a loud tone of voice. B) Begin and end with the most important information. C) Avoid repeating information to reduce confusion. D) Include as much information as possible in each teaching session.
B. Begin and end with the most important information Short-term memory is often reduced in older adults; therefore, repeating important information, and especially presenting it at the beginning and end, enhances retention. Speech at lower voice levels is better understood by the older adult. Repeating information does not create confusion but rather facilitates learning in the older adult. Older adults may have slower cognitive function and will remember more effectively if the information is paced properly.
7. When discussing the client's care with a nurse's aide, the nurse instructs the aide to report any coughing during meals in the client, who recently experienced a stroke and requires feeding. In this situation the nurse is acting as which of the following? A) Educator B) Delegator C) Client advocate D) On-the-job trainer
B. Delegator The nurse is delegating the task of feeding to the aide but is also providing directions.
6. Which theories describe an orderly process beginning with conception and continuing through death? A) Systems theories B) Developmental theories C) Interdisciplinary theories D) Stress and adaptation theories
B. Developmental theories Developmental theories discuss human growth from conception to death. The other options are incorrect
Which of the following characteristics of a goal is missing from the statement "Client will ambulate daily"? A) Observable B) Measurable C) Client centered D) Singular goal or outcome
B. Measurable Goals must be measurable, such as "Client will ambulate 15 feet daily." The other characteristics are met in this goal statement.
A nurse is caring for a client receiving enteral tube feedings due to dysphagia. Which of the following bed positions is appropriate for safe care of this client? A. Supine B. Semi-Fowler's C. Semi-prone D. Trendelenburg
B. Semi-Fowler's
When teaching is viewed as communication, then a specific learning objective can be said to be developed from: A) The message B) The referent C) Feedback D) Intrapersonal variables
B. The referent The referent is the perceived need for information. This provides the basis for the learning objective. The message refers to the information taught. Feedback is used to determine whether or not the learning objective was achieved. Intrapersonal variables are assessed to determine willingness and ability to learn.
The nurse is preparing to administer IV fluid to a client with a strict fluid restriction. IV tubing with which feature is most important for the nurse to use?
Buterol attachment
A nurse on a medical-surgical unit is informed that a mass casualty even occurred in the community and that it is necessary to discharge stable clients to make beds available for injury victims. Which of the following clients should the nurse recommend for discharge? Select all that apply. a. A client who is dehydrated and receiving IV fluid and electrolytes b. A client who has a nasogastric tube to treat a small bowel obstruction c. A client who is scheduled for elective surgery d. A client who has chronic hypertension and blood pressure 135/85 mm Hg e. A client who has acute appendicitis and is scheduled for an appendectomy
C, D
Maslow's hierarchy of needs is useful to nurses, who must continually prioritize a client's nursing care needs. The most basic or first-level needs include: A) Self-actualization B) Love and belonging C) Air, water, and food D) Esteem and self-esteem
C. Air, water, and food The first level of Maslow's hierarchy of needs includes the need for air, food, and water—basic elements of survival. Love and belonging are on the second level, esteem and self-esteem are on the fourth level, and self-actualization is the final level.
Which professionally appropriate response should the nurse make when a more stringent policy for the use of restraints is introduced on a surgical unit? A. Use the previous, less restrictive policy conscientiously B. Express immediate disagreement with the new policy C. Ask for the rationale behind the new policy D. Obey the policy but continue to voice disapproval of it to co-workers
C. Ask for the rationale behind the new policy Rationale: Understanding the rationale behind a decision helps the nurse analyze the proposed change and understand its purpose. Options 1, 2, and 4 represent unprofessional behavior. Option 1 also places a client's safety at risk.
A nurse in a provider's office is preparing to asses a young adult male client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? SELECT ALL THAT APPLY A. Concave thoracic spine posteriorly B. Exaggerated lumbar curvature C. Concave lumbar spine posteriorly D. Exaggerated thoracic curvature E. Muscles slightly larger on his dominant side
C. Concave lumbar spine posteriorly E. Muscles slightly larger on his dominant side
The client is a 65-year-old overweight woman with multiple medical diagnoses, including diabetes mellitus type 2, hypertension, and residual right-sided weakness resulting from a previous cerebrovascular accident. What tool should be used to plan her care? A) Care plan B) Care map C) Concept map D) Critical thinking
C. Concept map A concept map is a visual representation of client problems and interventions that shows their relationships to each other and allows easy synthesis of data about the client.
A client who is hospitalized has just been diagnosed with diabetes. He is going to need to learn how to give himself injections. The best teaching method would be: A) Role playing B) Simulation C) Demonstration D) Group instruction
C. Demonstration Demonstration with return demonstration is the best method to teach a psychomotor skill. Group instruction is not typically effective in teaching specific psychomotor skills, because it does not allow for individualized instruction. Role playing and simulation are not appropriate in this situation.
12. The client who is most ready to begin a client teaching session is the client who has: A) Experienced nausea and vomiting for the past 24 hours B) Just been told that he needs to have major surgery C) Voiced a concern about how insulin injections will affect her lifestyle D) Complained bitterly about the low-fat, low-cholesterol diet he must follow after his heart attack
C. Voiced a concern about how insulin injections will affect her lifestyle
A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? A. Sexual activity patterns. B. Nutritional history. C. Leisure activities. D. Financial stressors.
Caffeine, sugars, and alcohol can lead to increased levels of anxiety, so a nutritional history (C) should be obtained first so that health teaching can be initiated if indicated. (A and C) can be used for stress management. Though (D) can be a source of anxiety, a nutritional history should be obtained first. Correct Answer: B
At the beginning of the shift, the nurse assesses a client who is admitted from the post-anesthesia care unit (PACU). When should the nurse document the client's findings? A) At the beginning, middle, and end of the shift. B) After client priorities are identified for the development of the nursing care plan. C) At the end of the shift so full attention can be given to the client's needs. D) Immediately after the assessments are completed
D) Immediately after the assessments are completed Documentation should occur immediately after any component of the nursing process, so assessments should be entered in the client's medical record as readily as findings are obtained (D). (A, B, and C) do not address the concepts of legal recommendations for information management and informatics.
Which of the following statements reflects the current trend in the directives from the Centers for Disease Control and Prevention (CDC) for minimizing risks of infection? A) Discard all dressings into red bags. B) Do not recap bottles of solutions to minimize risk of contamination. C) Recap syringes or break needles off before discarding into sharps containers. D) Keep all drainage tubing below the level of the waist and/or site of insertion.
D) Keep all drainage tubing below the level of the waist and/or site of insertion. Keeping the solution in drainage tubes draining away from the drainage site on the body reduces the risk for bacteria growth. Running any solution backward in the tubing puts the client at risk by bringing any bacteria that may be present lower in the system back to the body, and cross contamination will occur. As in surgical areas, anything below the waist should be considered at potential risk for infection. Needles are not to be recapped or cut because of the increased risk of experiencing puncture wounds while doing so. Not all dressings need to be placed in red bags; only dressings with moisture require placement in a red bag. Bottles of solution that are sitting in the client's room should be closed to prevent airborne contaminants from entering and creating an unsterile situation.
When transferring a sterile item to a sterile field, the nurse should: A) Open the outer package and let the sterile assistant take the item from the nurse to put on the edge of the drape. B) Use a sterile lifting tool (forceps) to pick up the inner package and transfer it to the middle of the field. C) Open the outer package and use a sterile glove to pick up the item and drop it on the sterile field in the middle of the drape. D) Open the package by peeling back the cover without touching the inner package and drop the item within the sterile field without touching the 1-inch border.
D) Open the package by peeling back the cover without touching the inner package and drop the item within the sterile field without touching the 1-inch border. The rule is "sterile to sterile" to prevent contamination. The outer cover is considered unsterile. As long as the inner packet is not touched, the packet is considered sterile. The 1-inch border or barrier between the edge of the drape and the field is the dividing line for sterile versus nonsterile. Using a sterile glove to remove the inner packet is all right, but dropping it into the middle of the field will contaminate other items. A sterile assistant can take the item from the nurse, but placing it on the edge of the drape will contaminate the item because it is not inside the 1-inch border/barrier. Using sterile forceps to remove the inner packet is acceptable, but putting the item into the middle of the field will again risk potential contamination from reaching over the sterile field.
A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take? A) Explain that anyone who speaks her language can answer her questions. B) Provide a translator only in an emergency situation. C) Ask a family member or friend of the client to translate. D) Request and document the name of the certified translator.
D) Request and document the name of the certified translator A certified translator should be requested to ensure the exchanged information is reliable and unaltered. To adhere to legal requirements in some states, the name of the translator should be documented (D). Client information that is translated is private and protected under HIPAA rules, so (A) is not the best action. Although an emergency situation may require extenuating circumstances (B), a translator should be provided in most situations. Family members may skew information and not translate the exact information, so (C) is not preferred.
A nurse educator is conducting a parenting class for new parents of infants. Which of the following statements made by a participant indicates understanding of the instructions? A. "I will set my water heater at 130 F" B. "Once my baby can sit up, he should be safe in the bathtub" C. "I will place my baby on his stomach to sleep" D. "Once my infant starts to push up, I will remove the mobile from over the crib"
D. "Once my infant starts to push up, I will remove the mobile from over the crib"
A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include in her counseling? A. Carbon monoxide has a distinct color B. Water heaters should be inspected every 5 years C. The lungs are damaged from carbon monoxide inhalation D. Carbon monoxide binds with hemoglobin in the body
D. Carbon monoxide binds with hemoglobin in the body
In giving a change-of-shift report, which type of client information communicated by the nurse is most appropriate? A. Vital signs are stable B. Client is pleasant, alert, and oriented to time, place, and person C. The chest x-ray results were negative D. Client voided 250 mL of urine 2 hours after the urinary catheter removal
D. Client voided 250 mL of urine 2 hours after the urinary catheter removal Rationale: A change-of-shift report should include significant changes (good or bad) in a client's condition. The information should be accurate, concise, clear, and complete. Options 1 is vague and options 2 and 3 are normal data and are therefore of lesser importance to convey in the change-of-shift report.
The nurse reviews data regarding a client's pain symptoms, comparing the defining characteristics for Acute pain with those for Chronic pain. In the end the nurse selects Acute pain as the correct diagnosis. This is an example of avoiding which type of error? A) Error in data clustering B) Error in data collection C) Error in data interpretation D) Error in making a diagnostic statement
D. Error in making a diagnostic statement When a nurse compares collected assessment data with defining characteristics for two diagnoses, the selection of the correct diagnosis is an example of avoiding an error in making a diagnostic statement. There is no indication the data clustering or interpretation were incorrect.
Which of the following is objective information to be recorded in the client's medical record? A) Anxious over upcoming test. B) Increasing stress over past 2 months. C) Performs breast self-examination monthly. D) Expelled 1 tablespoon of yellow sputum.
D. Expelled 1 tablespoon of yellow sputum Objective data are measurable data. Options 1, 2, and 3 describe data that cannot be measured by the nurse but depend on the client's reports; thus they are subjective data.
One of the purposes of the use of standard formal nursing diagnostic statements is to: A) Evaluate nursing care. B) Gather information on client data. C) Help nurses to focus on the role of nursing in client care. D) Facilitate understanding of client problems by different health care providers.
D. Facilitate understanding of client problems by different health care providers. The use of standard formal nursing diagnostic statements provides a precise definition that gives all members of the health care team a common language for understanding the client's needs. The other options are not part of the reason for the development of nursing diagnostic statements.
During data clustering, a nurse: A) Provides documentation of nursing care B) Reviews data with other health care providers C) Makes inferences about patterns of information D) Organizes cues into patterns that lead to identification of nursing diagnoses
D. Organizes cues into paterns that lead to identification of nursing diagnoses During data clustering, the nurse organizes cues into patterns that indicate individualized nursing diagnoses and identify collaborative problems. The other options are incorrect.
When the nurse enter the room to enter vital signs in preparing the client for a dx test, the client is on the phone. What technique should the nurse use to determine the resp. rate? A. Count the resps during conversational pauses B. Ask the client to tend the phone call now and resume it at a later time. C. Wait at the client's bedside until the phone call is completed, then count resps D. Since there is no evidence of distress or urgency, defer the measurement
D. Since there is no evidence of distress or urgency, defer the measurement Since the client's needs always come first, delay the measurement unless it looks urgent.
The nurse has documented the following outcome goal in the care plan: "The client will transfer from bed to chair with two-person assist." The charge nurse tells the nurse to add which of the following to complete the goal? A. Client behavior B. Conditions or modifiers C. Performance criteria D. Target time
D. Target time Rationale: The outcome goal does not state the target timeframe for when the nurse should expect to see the client behavior ("transfer"). The condition or modifier is present ("with two assists"). The performance criterion is "from bed to chair."
Nursing's paradigm includes: A) Health, person, environment, and theory B) Concepts, theory, health, and environment C) Nurses, physicians, models, and client needs D) The person, health, environment/situation, and nursing
D. The person, health, environment/situation, and nursing Nursing's paradigm includes four linkages: the person, health, environment/situation, and nursing.
Evidence-based nursing practice is the end result of: A) Prescriptive theory B) Use of practical knowledge C) Application of theoretical knowledge D) Theory-generating and theory-testing research
D. Theory-generating and theory-testing research The result of theory-generating or theory-testing research is to increase the knowledge base of nursing. As these research activities continue, clients become the recipients of evidence-based nursing care.
In order to determine whether an intervention was successful, the nurse evaluates the success of attaining a goal. Which of the following is an example of an evaluation? A) Dressing changed every 8 hours using sterile technique. B) Client will ambulate 500 feet 4 times a day with minimal assistance. C) Client performed quadriceps-setting exercises to right leg every 4 hours. D) Wound filling in with granulation tissue is red to pink without signs of infection.
D. Wound filling in with granulation tissue is red to pink without signs of infection Evaluation occurs after an intervention and indicates degree of achievement of goal attainment. The qualifier "will" indicates that this is a future event and does not evaluate current attainment of goal. Doing an intervention is not evaluating whether it was effective or not.
When assessing the NG tube drainage, the nurse discovers rust colored flecks, which action should the nurse take?
Manually aspirate the gastric secretions
Central Obesity, in a prothrombotic state (prone to clots), proinflammatory state, dyslipidemia, elevated BP 135/85 These people WILL get heart disease & diabetes
Metabolic Syndrome
Nurse is caring for laboring client whose membrane ruptured 24 hours prior to admit. Based on record and current fetal monitor, which action should the nurse implement?
Prepare for C-section
Onset: 10-15 m Duration:2-4 hours Peak:1 hours Lispro (Humalog), Aspart, Apidra Give with breakfast
Rapid Acting
Hr is 150-250 no p wave (cant determine atrial rate) No Pulse: defibrillator, amiodarone, cpr, acls Pulse: cardiovert/amioderano
Vtach
cardiac cath
ambulate maybe 1 hour after
inserting a NG tube for severe abdominal pain
x ray, aspirate, auscultate
A nurse is teaching the parents of a toddler about discipline. Which of the following actions should the nurse suggest? a. Establish consistent boundaries for the toddler b. Place the toddler in a room with the door closed c. Inform the toddler how you feel when he misbehaves d. Use favorite snacks to reward the toddler
a. Establish consistent boundaries for the toddler
By the second postoperative day, a client has not achieved satisfactory pain relief. Based no this evaluation, which of the following actions should the nurse take, according to the nursing process? a. Reassess the client to determine the reasons for inadequate pain relief b. Wait to see whether the pain lessens during the next 24 hr c. Change the plan of care to provide different pain d. Teach the client about the plan of care for managing his pain
a. Reassess the client to determine the reasons for inadequate pain relief
Three levels of critical thinking in nursing have been identified. Briefly describe each: a. basic b. complex c. commitment
a. basic: the learner trusts that the experts have the right answers for every problem; thinking is concrete and based on a set of rules or principles b. complex: learners begin to separate themselves from experts and analyze and examine choices more independently c. commitment: learners anticipate the need to make choices without assistance from others and accept accountability
Questions to consider using in making a culturally competent nursing diagnosis: (a-e)
a. how has this health problem affected you and your family? b. what do you believe will help or fix the problem? c. what worries you the most about this problem? d. what do you expect from us to help you maintain some of your values or practices? e. what cultural practices do you keep to yourself well?
Which of the following strategies should a nurse use to establish a helping relationship with a client? a. Make sure the communication is equally reciprocal between the nurse and the client b. Encourage the client to communicate his thoughts and feelings c. Give the nurse-client communication no tome limits d. Allow communication to occur spontaneously throughout the nurse-client relationship
b. Encourage the client to communicate his thoughts and feelings
A nurse is caring for a competent adult client who tells the nurse that he is thinking about leaving the hospital against medical advice. The nurse believes that this is not in the client's best interest, so she prepares to administer a PRN sedative medication the client has not requested along with his usual medication. Which of the following types of tort is the nurse about the commit? a. Assault b. False imprisonment c. Negligence d. Breach of confidentiality
b. False imprisonment
A young adult client in a provider's office tells the nurse that she uses fasting for several days each week to help control her weight. The client takes several medications for various chronic issues. The nurse should explain to the client that which of the following mechanisms that results from fasting puts her at risk for medication toxicity? a. Increasing the metabolism of the medication over time b. Increasing the protein-binding response c. Increasing medications' transit time through the intestines d. Decreasing the excretion of medications
b. Increasing the protein-binding response
A nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse checks the client's medical record, discovers that she is allergic to the antibiotic, and calls the provider to request a prescription for a different antibiotic. Which of the following critical thinking attitudes did the nurse demonstrate? a. Fairness b. Responsibility c. Risk taking d. Creativity
b. Responsibility
A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following should the nurse use for safe care of this client? a. Supine b. Semi-Fowler's c. Semi-prone d. Trendelenburg
b. Semi-Fowler's
A nurse is preparing to instill an enteral feeding for a client who has an NG tube in place. Which of the following actions is the nurse's highest assessment priority before performing this procedure? a. Check how long the feeding container has been open b. Verify the placement of the NG tube c. Confirm that the client does not have diarrhea d. Make sure the client is alert and oriented
b. Verify the placement of the NG tube
A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the priority? a. A client who received crush injuries to the chest and abdomen and is expected to die b. A client who has a 4-inch laceration to the head c. A client who has partial-thickness and full-thickness burns to his face, neck, and chest d. A client who has a fractured fibula and tibia
c. A client who has partial-thickness and full-thickness burns to his face, neck, and chest
A nurse is caring for a client who reports pain with internal rotation of her right shoulder. The nurse should identify that this discomfort can affect the client's ability to perform which of the following activities? a. Mopping her floors b. Brushing the back of her hair c. Fastening her bra behind her back d. Reaching into a cabinet above her sink
c. Fastening her bra behind her back
A nurse receives a laboratory report for a client indicating a potassium level of 5.2 mEq/L. When notifying the provider, the nurse should anticipate which of the following actions? a. Starting an IV infusion of 0.9% sodium chloride b. Consulting with dietitian to increase intake of potassium c. Initiating continuous cardiac monitoring d. Preparing the client for gastric lavage
c. Initiating continuous cardiac monitoring
A nurse is teaching a client who is lactating about taking medications. Which of the following actions should the nurse recommend to minimize in the entry of medication into breast milk? a. Drink 8 oz milk with each dose of medication b. Use medications that have an extended half-life c. Take each dose right after breastfeeding d. Pump breast milk and freeze it prior to feeding to the newborn
c. Take each dose right after breastfeeding
A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray? a. Cooked barley b. Pureed broccoli c. Vanilla custard d. Lentil soup
c. Vanilla custard
Clinical Decision Making
careful reasoning so the best options are chosen for the best outcomes
after administering a medication through NG tube
clamp the tube
Drawing insulin
clear (regular) into cloudy (NPH)
myopia
difficultly visualizing objects at a distance
Patient receiving Morphine in PCA pump
make sure the lock is on the machine
Which intervention would nurse expect to decrease discomfort and muscle spasms in elderly patient with fractured left hip?
prepare client for application of Buck's traction
older adult safety concerns
prevent accidents, orient person to surroundings, avoid falls, maintain vehicle in working order, schedule eye exams, and keep noise at a minimum, promote safe environment at home, use med trays
reason for the administration of heparin with a pulmonary embolus is to
prevent embolus recurrence
protocol for airborne transmission
private room, negative pressure with 6-12 air exchanges/hr, mask n95 for TB
Describe motivational interviewing:
process that addresses a patient's ambivalence to medically indicated behavior change and supports patients in making health care decisions
A child is brought to the clinic complaining of fever and joint pain is diagnosed with rheumatic fever. When planning care for this child what is the primary goal of nursing?
reduce fever
antitussive
reduce the frequency of cough
Nurse observes client standing with use of crutches and notes that arms are fully extended and tops of crutches are severely pressed into axillae. What intervention?
reduce the length of the crutches
The nurse notices that a patient has spoon-shaped brittle nails. This suggests that the patient is experiencing Imbalanced Nutrition: Less than body requirements related to deficiency to which nutrient? 1) Iron 2) Vitamin A 3) Protein 4) Vitamin C
1) Iron
You auscultate a client's abdomen as part of a focused physical assessment for bowel elimination. You hear high-pitched sounds, with about 10 gurgles in a minute. Which of the following conditions is most associated with this type of bowel sound? 1) Normal 2) Small bowel obstruction and diarrhea 3) Decreased peristalsis and constipation 4) Paralytic ileus following abdominal surgery
1) Normal
Which of the following characteristics do the various definitions of critical thinking have in common? 1) Requires reasoned thought 2) Asks the questions "why" and "how" 3) Is a hierarchal process 4) Demands specialized thinking skills
1) Requires reasoned thought
A nurse is discussing direct and indirect contact modes of transmission of infection at a staff education session. Which of the following incidents are examples of direct mode of transmission? Select all that apply. a. A client vomits on a nurse's uniform b. A nurse has a needle stick injury c. A mosquito bites a hiker in the woods d. A nurse finds a hole in his glove while handling soiled dressing e. A person fails to wash her hands after using the bathroom
A, D
A nurse uses an institution's procedure manual to confirm how to insert a Foley catheter. The level of critical thinking the nurse is using is: A. Commitment B. Scientific method C. Basic critical thinking D. Complex critical thinking
C. Basic critical thinking At the basic level of critical thinking, a learner trusts the experts and follows a procedure step by step. Complex critical thinkers separate themselves from authorities and analyze and examine choices more independently. Commitment is the third level of critical thinking in which the person anticipates the need to make choices without assistance from others. The scientific method is a process of problem solving.
The purpose of assessment is to: A) Make a diagnostic conclusion. B) Delegate nursing responsibility. C) Teach the client about his or her health. D) Establish a database concerning the client.
D. Establish a database concerning the client The purpose of assessment is to establish a database about the client's perceived needs, health problems, and responses to these problems. The data also reveal related experiences, health practices, goals, values, and expectations. The other options are not purposes of assessment.
Reviewing the following: 38 year old, growth in height 5'2", female gender, weight gain 15 lbs. This list can be reffered to as which of the following? 1) information 2) knowledge 3) data 4) patient record
1) information
Which food provides the body with no usable glucose? 1) wheat germ 2) apples 3) white bread 4) white rice
1) wheat germ
assessing pitting edema
1+ 2mm 2+ 4mm 3+ 6mm 4+ 8mm
Unmet and partially met goals require the nurse to do which of the following? (Select all that apply) [20] 1. Redefine priorities 2. Continue intervention 3. Discontinue care plan 4. Gather assessment data on a different nursing diagnosis 5. Compare the patient's response with that of another patient
1, 2
How does the nurse support a culture of safety? (Select all that apply) [27] 1. Completing incident reports when appropriate 2. Completing incident reports for a near miss 3. Communicating product concerns to an immediate supervisor 4. Identifying the person responsible for an incident
1, 2, 3
Review the following nursing diagnoses and identify the diagnoses that are correctly stated. (Select all that apply) [17] 1. Anxiety related to fear of dying 2. Fatigue related to chronic emphysema 3. need for mouth care related to inflamed mucosa 4. Risk for infection
1, 4
The nurse is preparing to administer eardrops to a client that has impacted cerumen. Before administering the drops, the nurse will assess the client for which contraindications? Select all that apply. 1 Allergy to the medication 2 Itching in the ear canal 3 Drainage from the ear canal 4 Tympanic membrane rupture 5 Partial hearing loss in the affected ear
1,3,4 Contraindications to eardrops include allergy to the medication, drainage from the ear canal, and tympanic membrane rupture. Partial hearing loss may occur with impacted cerumen and is not a contraindication to the use of eardrops. Itching may occur with some ear conditions and is not a contraindication to the use of eardrops.
You are talking with a client who recently started lifting free weights three days a week to improve strength. Which of the following types of exercise is this? 1) Isometric anaerobic 2) Isotonic aerobic 3) Isotonic anaerobic 4) Isokinetic aerobic
3) Isotonic anaerobic
Which of the following is an example of an active listening behavior? 1) Taking frequent notes 2) Asking for more details 3) Leaning in, facing the patient 4) Sitting with legs crossed
3) Leaning in, facing the patient
From what stage of sleep are people typically most difficult to arouse? 1) NREM alpha waves 2) NREM sleep spindles 3) NREM delta waves 4) REM
3) NREM delta waves
A person who is deprived of REM sleep for several nights in succession will usually experience: 1) extended NREM sleep 2) paradoxical sleep 3) REM rebound 4) insomnia
3) REM rebound
You are caring for an older client with Alzheimer's disease. You are concerned about this client getting out of bed unassisted and falling. Which of the following would be the best intervention to prevent this from occurring? 1) Install full-length siderails on the client's bed and raise them all the way up. 2) Apply a cloth vest restraint to the client. 3) Use a bed alarm with the client and conduct hourly rounds to observe her. 4) Explain the risk of falling to the client and ask her to call for assistance when she needs to get up.
3) Use a bed alarm with the client and conduct hourly rounds to observe her.
You are caring for an older client who has lost 5 pounds since being admitted to the hospital and is significantly underweight. Which of the following measures should you take to help stimulate this client's appetite? SELECT ALL THAT APPLY. 1) Offer less frequent, larger meals. 2) Encourage greater liquid intake with meals. 3) Warm the client's food if it cools off before the client has a chance to eat it. 4) Vary the textures, colors, and flavors of the food served. 5) Position the person comfortably. 6) Encourage meals with friends.
3) Warm the client's food if it cools off before the client has a chance to eat it. 4) Vary the textures, colors, and flavors of the food served. 5) Position the person comfortably. 6) Encourage meals with friends.
You are caring for a client who has been prescribed antibiotics. Knowing that this type of medication often causes diarrhea, which of the following foods should you encourage the client to consume to prevent this side effect? 1) Fresh fruits and vegetables 2) Coffee 3) Yogurt 4) Whole grain bread
3) Yogurt
A patient has an area of non-blancheable erythemia on his coccyx. The nurse has determined this to be a stage I pressure ulcer. What would be the most important treatment for this patient? 1) transparent film dressing 2) sheet hydrogel 3) frequent turn schedule 4) debridement
3) frequent turn schedule
Which electrolyte is the primary regulator of fluid volume? 1) potassium 2) calcium 3) sodium 4) megnesium
3) sodium
__________________ is the use of telecommunications to send healthcare information between patients and professionals at different locations. 1) informatics 2) NANDA 3) telehealth 4) MAR
3) telehealth
Which of the following behaviors indicates the highest potential for spreading infectious among patients. The nurse ___________________ 1) disinfects dirty hands with antibacterial soap. 2) allows alcohol-based rub to dry for 10 seconds 3) washes hands only after leaving patients room 4) uses cold water for medical asepsis.
3) washes hands only after leaving patients room Healthcare workers need to have clean hands before and after going into a patients room.
During the implementation step of the nursing process, a nurse reviews and revises the nursing plan of care. Place the following steps of review and revision in correct order: [19] 1. Review the care plan 2. Decide if the nursing interventions remain appropriate 3. Reassess the patient 4. Compare assessment findings to validate existing nursing diagnoses
3, 1, 4, 2
A nurse is sued for failure to monitor a patient appropriately after a procedure,. Which of the following statements are correct about this lawsuit? (Select all that apply) [23] 1. The nurse represents the plaintiff. 2. The defendant must prove injury, damage, or loss. 3. The person filing the lawsuit has the burden of proof. 4. The plaintiff must prove that a breach in the prevailing standard of care caused an injury.
3, 4
The family of a patient who is confused and ambulatory insist that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply) [27] 1. Contact the nursing supervisor 2. Restrict the family member's visiting privileges 3. Ask the family to stay with the patient if possible 4. Inform the family of the risks associated with side-rail use 5. Thank the family for being conscientious and put the four rails up 6. Discuss alternatives with the family that are appropriate for this patient
3, 4, 6
A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency? Select all that apply. 1 Diplopia 2 Skin rash 3 Leg cramps 4 Tachycardia 5 Muscle weakness
3,5 Leg cramps occur with hypokalemia because of potassium deficit. Muscle weakness occurs with hypokalemia because of the alteration in the sodium potassium pump mechanism. Diplopia does not indicate an electrolyte deficit. A skin rash does not indicate an electrolyte deficit. Tachycardia is not associated with hypokalemia, bradycardia is.
A family member is providing care to a loved care who has an infected leg wound. What would you instruct the family member to do after providing care and handling contaminated equipment or organic material? [28] 1. Wear gloves before eating or handling food 2. Place any soiled materials into a bag and double bag it 3. Have the family member check with the doctor about need for immunization 4. Perform hand hygiene after care and/or handling contaminated equipment or material
4
A nurse is preparing to administer acetaminophen 320 mg PO every 4 hr PRN for pain. The amount available is acetaminophen liquid 160 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Do not use a trailing zero.)
10 mL
Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received?
11,000 units
A goal specifies the expected behavior or response that indicates: [20] 1. The specific nursing action was completed 2. The validation of the nurse's physical assessment 3. The nurse has made the correct nursing diagnoses 4. Resolution of a nursing diagnosis or maintenance of a healthy state
4
A homeless man enters the emergency department seeking health care. The health care provider indicates that the patient needs to be transferred to the City Hospital for care. This action is most likely a violation of which of the following laws? [23] 1. Health Insurance Portability and Accountability Act (HIPPA) 2. Americans with Disabilities Act (ADA) 3. Patient Self-Determination Act (PSDA) 4. Emergency Medical Treatment and Active Labor Act (EMTALA)
4
A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been in, but your appointment was for every 2 months. Tell me about that. Also, I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you have been following his plan?" The nurse's assessment covers which of Gordon's functional health patterns? [16] 1. Value-belief pattern 2. Cognitive-perceptual pattern 3. Coping-stress-tolerance pattern 4. Health perception-health management pattern
4
Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibit formation of aqueous humor for a client with glaucoma? 1 Chlorothiazide (Diuril) 2 Acetazolamide (Diamox) 3 Bendroflumethiazide (Naturetin) 4 Demecarium bromide (Humorsol)
2
You are providing nutritional counseling to the mother of an infant. She is wondering at what age she should start feeding her child solid food. Which of the following should you tell her? 1) 2 to 4 months 2) 4 to 6 months 3) 6 to 8 months 4) 8 to 10 months
2) 4 to 6 months
When a nurse properly positions a patient and administers an enema solution at the correct rate for the patient's tolerance, this is an example of what type of implementation skill? [19] 1. Interpersonal 2. Cognitive 3. Collaborative 4. Psychomotor
4
You are performing a physical examination on an obese client. Which of the following findings would most cause you to suspect that the client might be diabetic? 1) Sweating 2) Fruity breath 3) Shakiness 4) Anxiety
2) Fruity breath
One of your clients has recently taken a job in road construction. Which of the following are adverse health effects associated with substantial exposure to loud noises that you should warn the client about, to encourage him to use hearing protection? SELECT ALL THAT APPLY. 1) Respiratory disease 2) Hearing loss 3) Stress 4) Cancer 5) Elevated blood pressure 6) Loss of sleep
2) Hearing loss 3) Stress 5) Elevated blood pressure 6) Loss of sleep
Which point(s) should the nurse include when teaching safety precautions to a mother of a toddler? Select all that apply. 1) Make sure the child sleeps on his back 2) Keep the telephone number of poison control center nearby 3) Use a front-facing car seat placed in the back seat 4) Keep syrup of ipecac on hand in case of poisoning
2) Keep the telephone number of poison control center nearby 3) Use a front-facing car seat placed in the back seat Infants, not toddlers should sleep on their backs, and syrup of ipacac is no longer a recommendation to induce vomiting after poisoning.
Skin integrity and wound healing are compromised in a patient who takes blood pressure medications because antihypertensives: 1) cause cellular toxicity 2) increase the risk of ischemia 3) delay wound healing 4) predispose to hematoma formation
2) increase the risk of ischemia
You are admitting a 54 year old with COPD. The physician describes the O2 at 24% F io2. What is the appropriate oxygen delivery method for this patient? 1) Nasal canula 2) nonrebreather mask 3) trach collar 4) venturi mask
2) nonrebreather mask
The nurse checks a patient's pupils using a pen light, which receptor is the nurse stimulating? 1) chemoreceptors 2) photoreceptors 3) proprioceptors 4) mechanoceptors
2) photoreceptors
A 58-year-old patient with nerve deafness has come to his doctor's office for a routine examination. The patient wears two hearing aids. The advanced practice nurse who is conducting the assessment uses which of the following approaches while conducting the interview with this patient? (Select all that apply) [16] 1. Maintain a neutral facial expression 2. Lean forward when interacting with the patient 3. Acknowledge the patient's answers through head nodding 4. Limit direct eye contact
2, 3
Bathing a patient with liver dysfunction, the nurse notes yellow skin tone. The nurse should document this finding as: 1) Edema 2) Jaundice 3) Cyanosis 4) Pallor
2) Jaundice
Identify the interval when a patient progresses from nonspecific signs to manifesting signs and symptoms specific to a type of infection. [28] 1. Illness stage 2. Convalescence 3. Prodromal stage 4. Incubation period
3
A client you are caring for seems to produce little urine. You suspect that the client's diet is the cause. A diet heavy with which of the following foods would explain this decreased urine production? 1) Beer 2) Coffee 3) Salty potato chips 4) Chocolate
3) Salty potato chips
Most digestion and absorption of food occurs in which of the following structures of the gastrointestinal system? 1) Esophagus 2) Stomach 3) Small intestine 4) Large intestine
3) Small intestine
Computers are important for evidence-based practice because: 1) they are available in all healthcare settings 2) extra training is not required 3) information can be processed and managed more efficiently 4) all the best evidence is located on a computer
3) information can be processed and managed more efficiently
A child in the hospital starts to have a grand mal seizure while playing in the playroom. What is your most important nursing intervention during this situation? [27] 1. Begin cardiopulmonary resuscitation 2. Restrain the child to prevent injury 3. Place a tongue blade over the tongue to prevent aspiration 4. Clear the area around the child to protect the child from injury
4
A patient has limited mobility as a result of a recent knee replacement. The nurse identifies that he has altered balance and assists him in ambulation. The patient uses a walker presently as part of his therapy. the nurse notes how far the patient is able to walk and then assists him back to his room. Which of the following is an evaluative measure? [20] 1. Uses walker during ambulation 2. Presence of altered balance 3. Limited mobility in lower extremities 4. Observation of distance patient is able to walk
4
A nurse is caring for a client who has several risk factors for hearing loss. Which of the following medications, that the client currently takes, should alert the nurse to a further risk for ototoxicity? a. Furosemide b. Ibuprofen c. Cimetidine d. Simvastatin e. Amiodarone
A, B
A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? Select all that apply. a. Keep the head of the bed elevated 30 degrees b. Massage the client's bony prominences frequently c. Apply cornstarch liberally to the skin after bathing d. Have the client sit on a gel cusion when in a chair e. Reposition the client at least every 3 hr while in bed
A, D
A nurse is assigned to a new patient admitted to the nursing unit following admission through the emergency department. The nurse collects a nursing history and interviews the patient. Place the following steps for making a nursing diagnosis in the correct order. [17] 1. Considers context of patient's health problem and selects a related factor 2. Reviews assessment data, noting objective and subjective clinical criteria 3. Clusters clinical criteria that form a pattern 4. Chooses diagnostic label
2, 3, 4, 1
The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20mg/2ml. How many ml should the nurse administer? a. 1 ml b. 1.5ml c. 1.75ml d. 2ml
Answer: b. 1.5mL Rationale: 20mg / 2ml = 10mg/1ml 1.5 x 10 = 15
The following statement appears on the nursing care plan for an immunosuppressed patient: "the patient will remain free from infection throughout hospitalization" this statement is an example of an: a. long term goal b. short term goal c. nursing diagnosis d. expected outcome
Answer: b. short term goal Rationale: an objective behavior or response that you expect a patient to achieve in a short time, usually less than 1 week
The nurse in a geriatric clinic collects the following information from an 82-year-old patient and her daughter, the family caregiver. The daughter explains that the patient is "always getting lost." The patient sits in the chair but gets up frequently and paces back and forth in the examination room. The daughter says, "I just don't know what to do because I worry she will fall or hurt herself." The daughter states that, when she took her mother to the store, they became separated, and the mother couldn't find the front entrance. The daughter works part time and has no one to help watch her mother. Which of the data form a cluster, showing a relevant pattern? (Select all that apply) [17] 1. Daughter's concern of mother's risk for injury 2. Pacing 3. Patient getting lost easily 4. Daughter working part time 5. Getting up frequently
2, 3, 5
The nurse completed the following assessment: 63-year-old female patient has had abdominal pain for 6 days. She reports not having a bowel movement for 4 days, whereas she normally has a bowel movement every 2-3 days. She has not been hospitalized in the past. Her abdomen is distended. She reports being anxious about upcoming tests. Her temperature was 37 C, pulse 82 and regular, blood pressure 128/72. Which of the following data form a cluster, showing a relevant pattern? (Select all that apply) [17] 1. Vital sign results 2. Abdominal distension 3. Age of patient 4. Change in bowel elimination pattern 5. Abdominal pain 6. No past history of hospitalization
2, 4, 5
The nurse found a 68-year-old female patient wandering in the hall. The patient says she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply) [27] 1. Insert a urinary catheter 2. Leave a night light on in the bathroom 3. Ask the physician to order a restraint 4. Keep the bed in low position with upper and lower side rails up 5. Assign a staff member to stay with the patient 6. Provide scheduled toileting during the night shift 7. Keep the pathway from the bed to the bathroom clear
2, 6, 7
A nurse is assessing an older adult client who has significant tenting of the skin over his forearm. Which of the following factors should the nurse consider as a cause for this finding? Select all that apply. A. Thin, parchment-like skin b. Loss of adipose tissue c. Dehydration d. Diminished skin elasticity e. Excessive wrinkling
B, C, D
Someone with wound vac, how to make sure it is effective
Check seal to make sure there are no leaks
The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia? Select all that apply. Incorrect 1 Dyspnea 2 Flushed face 3 Precordial pain 4 Increased pulse rate 5 Increased blood pressure
2,4 Increased body heat dilates blood vessels, causing a flushed face. The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may not cause difficult breathing. Pain is not related to fever. Blood pressure is not expected to increase with fever.
A nurse is observing the appearance of an older client's eyes. Which finding warrants immediate intervention?
Conjunctival sclera are pale
overweight BMI
25 to 30
The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next?
Flush the tube with water.
The nurse is preparing to administer a high volume saline enema to a client. Which information is most important for the nurse to obtain prior to administering the enema?
History of inflammatory bowel disorders; diarrhea, hematuria, perforation
The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior?
Hot remedies restore balance after surgery, which is considered a "cold" condition.
Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding?
Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.
Ultra Lente, Glargine (LANTUS) Onset: 1 hr Duration: 24 hrs NO PEAK
Long Acting
blood seeps & protein leaks out, leads to blindness (diabetic retinapothy)
Microvascualr Angiopathy
23.Which client assessment data is most important for the nurse to consider before ambulating a postoperative client? A. Respiratory rate. B. Wound location. C. Pedal pulses. D. Pain rating.
Mobilization and ambulation increase oxygen use, so it is most important to assess the client's respiratory rate (A)before ambulation to determine tolerance for activity. (B, C, and D) are also important, but are of lower priority than (A). Correct Answer: A
In what ways has nursing evolved?
Nursing is no longer considered a "less than" job and instead is recognized as a highly respected profession. Practice has widened to cover a wide variety of health care settings. Nurses have a specific body of knowledge. Nurses have an ethical conduct. Nurses value research and continuously publish scholarly research. Nurses don't just "care for sick people;" nurse promote health as well. Nursing is continuously growing as a highly professional discipline.
Determining the client position for insertion of indwelling. Most important
Orthopnea
Planning involves:
Prioritizing the diagnoses, setting patient centered goals and expected outcomes, prescribing individualized nursing interventions
What is a law?
Standard or rule of conduct established and enforced by government.
A nurse caring for a patient with pneumonia sits the patient up in bed and suctions his airway. After suctioning, the patient describes some discomfort in his abdomen. The nurse auscultates the patient's lung sounds and gives him a glass of water. Which of the following is an evaluative measure used by the nurse? [20] 1. Suctioning the airway 2. Sitting the patient up in bed 3. Auscultating lungs sounds 4. Patient describing type of discomfort
3
List the communication skills that are needed to effectively communicate (a-d)
a. courtesy b. comfort c. connection d. confirmation
List the 3 phases of patient-centered interviews (a-c)
a. orientation and setting an agenda b. working phase: collecting assessment c. terminating an interview
A nurse is performing an integumentary assessment for a group of clients. Which of the following findings should the nurse recognize as requiring immediate intervention? a. Pallor b. Cyanosis c. Jaundice d. Erythema
b. Cyanosis
guaiac and vitamin k
blood in stool after a guaiac test my be caused by vitamin k deficiency
Health promotion nursing diagnosis
desire to increase well-being and actualize human health potential
new plaster cast is applied to arm for fracture of ulna, an hour later patient complains of pain 10/10 check for
distal paresthesia
Integrity
do not compromise nursing standards of honesty in delivering nursing care
Precautions for RSV
do not put patient with another RSV patient
disinfecting
elimination of many or all microorganisms except bacterial spores from inanimate objects complete
Reflective practice is . . .
essential to professional practice.
Bioethics =
ethics dealing with human lives
patient with recurrent SOB just had a bronchoscopy
monitoring patient for laryngeal edema
pulse 60-100 beats per min
normal
process of inflammation does not include
tingling and itching
You are caring for a client who recently had a portion of intestine made into a reservoir that is connected to the urethra. The patient will need to void by bearing down or applying manual pressure over the bladder. Which of the following urinary diversions does this client have? 1) Cutaneous ureterostomy 2) Conventional urostomy 3) Continent urinary reservoir 4) Neobladder
4) Neobladder
Which nursing activities are examples of primary prevention? Select all that apply. 1 Preventing disabilities 2 Correcting dietary deficiencies 3 Establishing goals for rehabilitation 4 Assisting with immunization programs 5 t
4,5 Immunization programs prevent the occurrence of disease and are considered primary interventions. Stopping smoking prevents the occurrence of disease and is considered a primary intervention. Preventing disabilities is a tertiary intervention. Correcting dietary deficiencies is a secondary intervention. Establishing goals for rehabilitation is a tertiary intervention.
if client has not voided withihn ___ hours
8 hours,
Sinus bradycardia is a dysrhythmia that proceeds normally through the conduction pathway but at a slower than usual (≤60 beats/minute) rate. Sinus bradycardia is a slower than usual (≤60 beats/minute) heart rate.
A 66-year-old female client is having cardiac diagnostic tests to determine the cause of her symptoms. In her follow-up visit to the cardiologist, she is told that she has a dysrhythmia at a rate slower than 60 beats/minute. What type of dysrhythmia did the tests reveal?
7.A 73-year-old Hispanic client is seen at the community health clinic with a history of protein malnutrition. What information should the nurse obtain first? A. Amount of liquid protein supplements consumed daily. B. Foods and liquids consumed during the past 24 hours. C. Usual weekly intake of milk products and red meats. D. Grains and legume combinations used by the client.
A client's dietary habits should be determined first by the client's dietary recall (B) before suggesting protein sources or supplements (A and C) as options in the client's diet. Although grains and legumes (D) contain incomplete proteins that reduces the essential amino acid pools inside the cells, the client's cultural preferences should be illicited after confirming the client's dietary history. Correct Answer: B
Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? A) 11,000 units. B) 13,000 units. C) 15,000 units. D) 17,000 units
A) 11,000 units
A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? A. Autopsy of the body is prohibited. B. Blood transfusions are forbidden. C. Alcohol use in any form is not allowed. D. A vegetarian diet must be followed.
Blood transfusions are forbidden (B) in the Jehovah's Witness religion. Judaism prohibits (A). Buddhism forbids the use of (C) and drugs. Many of these sects are vegetarian (D), but the direct impact on nursing care is (B). Correct Answer: B
Which of the following represents the most complex behavior in the psychomotor learning domain? A) Accepting the limitations imposed by a stroke B) Understanding the relationship of insulin, diet, and exercise in diabetes C) Performing self-catheterization without acquiring a urinary tract infection D) Performing activities of daily living after acquiring left-sided paralysis due to a brain injury
D. Performing activities of daily living after acquiring left-sided paralysis due to a brain injury Origination is the most complex behavior in the psychomotor learning domain. It is highly complex and involves developing new psychomotor skills and abilities from existing ones, as is seen in paralysis. Accepting limitations is a behavior in the affective learning domain. Understanding relationships is a behavior in the cognitive learning domain. Option 3 is a psychomotor learning behavior that is referred to as complex overt response, in which the client performs a motor skill using a complex movement pattern. It is not as complex as origination.
During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure?
Degree of flexion and extension of the client's knee joint.
Before removing surgical wound staples, what assessment is most important for the nurse to complete?
Determine the level of incisional pain
A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement?
Ensure the accuracy of the blood type match.
Hep A vaccine - patient with greatest risk?
Female who regularly consumes raw oysters
When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first? A. Establish a new nursing diagnosis. B. Note which actions were not implemented. C. Add additional nursing orders to the plan. D. Collaborate with the healthcare provider to make changes.
First, the nurse reviews which actions in the original plan were not implemented (B) in order to determine why the original plan did not produce the desired outcome. Appropriate revisions can then be made, which may include revising the expected outcome, or identifying a new nursing diagnosis (A). (C) may be needed if the nursing actions were unsuccessful, or were unable to be implemented. (D) other members of the healthcare team may be necessary to collaborate changes once the nurse determines why the original plan did not produce the desired outcome. Correct Answer: B
A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement?
Give an around-the-clock schedule for administration of analgesics.
A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement?
Give the missed dose at 1300 and change the schedule to administer daily at 1300.
Hypoglycemia
Glucagon is used primarily to treat a patient with
HIPAA =
Health Insurance Portability and Accountability Act
The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective?
I will limit my intake of beef to 4 ounces per week.
The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take?
Infuse 10 percent dextrose and water at 54 ml/hr.
a male client sustained a burn injury to more than 25% of his body in a fire. Which intervention is most important in this emergency phase?
Infuse intravenous fluids as prescribed
A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time?
Initiate an alternate site for the IV infusion of the medication.
At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence?
It is OK if you don't want to talk about your surgery. I will be available when you are ready.
A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan?
Place a pillow between your knees while lying in bed to prevent hip dislocation.
Toddler with hemophilia is discharged from hospital What teaching?
Place padding on the corners of all furniture
Teaching a patient how tho walk with crutches
Place weight on arms and hands when using crutch
patient with a recent history of dry cough has had a chest x-ray that shows presence of nodules
Positron emission tomography (PET)
The type of theory that tests the validity and predictability of nursing interventions is: A) A grand theory B) A descriptive theory C) A prescriptive theory D) A middle-range theory
Prescriptive theory addresses nursing interventions and predicts the consequence of a specific nursing intervention. Middle-range theories are limited in scope, less abstract than grand theories, address specific phenomena or concepts, and reflect practice. Descriptive theories describe phenomena, speculate as to why the phenomena occur, and describe the consequences of phenomena. Grand theories are broad and complex.
QRS always widened Treat with lidocaine Irregular rythm Can lead to vtach or vfib
Pvc
52.The nurse removes the dressing on a client's heel that is covering a pressure sore one-inch in diameter and finds that there is straw-colored drainage seeping from the wound. What description of this finding should the nurse include in the client's record? A. Stage 1 pressure sore draining sero-sanguineous drainage. B. Pressure sore at bony prominence with exudate noted. C. One-inch pressure sore draining serous fluid. D. Pressure sore on heel with a small amount of purulent drainage.
Serous drainage is clear watery plasma, so (C) provides accurate documentation based on the information provided. Information to stage this pressure score (A) is not provided, and sero-sanguineous drainage is pale and watery with a combination of plasma and red cells, and may be blood-streaked. Exudate (B) is fluid such as pus and serum. Purulent drainage (D) is thick, yellow, green, or brown indicating the presence of dead or living organisms and white blood cells. Correct Answer: C
What is provision 3 of the code of ethics?
The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.
Social justice -
Upholding moral, legal, and humanistic rights
Immediate defibrillation Explanation: Defibrillation is used during pulseless ventricular tachycardia, ventricular fibrillation, and asystole (cardiac arrest) when no identifiable R wave is present.
You enter your client's room and find him pulseless and unresponsive. What would be the treatment of choice for this client?
Realistic
a realistic goal or outcome is one that a patient is able to achieve
Timed
a time-limited outcome is written so that it indicates when the nurse expects the response to occur
A nurse is instructing an assistive personnel (AP) about caring or a client who has a low platelet count as a result of chemotherapy. Which of the following instructions is the priority for measuring vital signs for this client? a. "Do not measure the client's temperature rectally." b. "Count the client's radial pulse for 30 seconds and multiply it by 2." c. "Do not let the client know you are counting her respirations." d. "Let the client rest for 5 minutes before you measure her blood pressure."
a. "Do not measure the client's temperature rectally."
latex allergies
assess for allergies to bananas, apricots, cherries, grapes, kiwis, passion fruit, avocado
A nurse is collecting data for a client's comprehensive physical examination. After the nurse inspects the client's abdomen, which of the following skills of the physical examination process should she perform next? a. Olfaction b. Auscultation c. Palpation d. Percussion
b. Auscultation
A nurse is collecting data from a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the client's pain? a. Ask the client what precipitates the pain b. Question the client about the location of the pain c. Offer the client a pain scale to measure his pain d. Use open-ended questions to identify the client's pain sensations
c. Offer the client a pain scale to measure his pain
Problem focused nursing diagnosis
clinical judgment concerning an undesirable human response to a health condition or life processes
A nurse instructor is explaining the various stages of the lifespan to a group of nursing students. Which of the following examples should the nurse include as a developmental task for middle adulthood? a. The client evaluates his behavior after a social interaction b. The client states he is learning to trust others c. The client wishes to find meaningful friendships d. The client expresses concerns about the next generation
d. The client expresses concerns about the next generation
nursing intervention with highest priority when completing DC teaching for H. Pylori induced peptic ulcer
instruct patient to take all antibiotic, PPI, and pepto-bismol
Errors in data clustering:
insufficient cluster of cues, premature or early closure, incorrect clustering
Torts may be . . .
intentional or unintentional.
because a hospitalized elderly female client who ambulates with a walker is receiving diuretics which results in frequent trips to the bathroom at night, the nurse should perform which of the following
leave bathroom light on provide bedside commode keep the side rails up
in assessing bowel sounds it is most important for nurse (select all)
listen for up to 5 minutes when auscultating inspect first and then auscultate for bowel sounds before percussing and palpating
Fairness
listen to both sides in any discussion
macules
localized flat skin discolorations less than 1 cm in diamter
Creativity
look for different approaches if interventions are not working
Male tells nurse that he does not want to receive blood that is needed for internal hemorrhage. What action should the nurse implement?
notify HCP of client refusal
jugular venous distention and pedal edema. What action?
notify the HCP of onset of right sided heart failure
heart rate
number of contractions of left ventricle in 1 minute
"nursing handoffs"
nurses collaborate and share information that ensures the continuity of care for a patient and prevents errors or delays in providing nursing interventions
Short term goal
objective behavior that you expect the patient will achieve in a short time
which nursing intervention has the highest priority for a multigravida client who delivered vaginal 12 hours ago
observe appropriate interaction with the infant multigravida = pregnant for at least 3rd time
while ambulating a patient with metastatic lung cancer, a drop in oxygen saturation from 93 to 86 %
obtain a physician's order for supplemental oxygen to be used during administration and other activity
Problem Solving
obtain information and then use the information plus what you already know to find a solution
In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly
often follows relocation to new surroundings.
List some types of nursing assessments:
patient centered interview during the history and physical exam and periodic assessments during rounding or administering care
portal of exit
point of escape for the origin
during immediate postanesthesia period the unconcious patient should be positioned on the side to maintain an open airway and promote drainage of secretions
position client on their side post op
how should the rn teach the UAP to position the chair to ensure a safe transfer
position the chair at a 45 degree angle to the bed on the left side (right is the patient's side with weakness)
Patient admitted to the psych unit and is on clozapine. Which intervention?
report findings from the client's weekly WBC and counts to the HCP
patient's o2 drops to 80%
reposition finger clip and obtain another reading assess for signs/symptoms of respiratory distress encourage cough / deep breathing
nursing action to prevent pressure sores
reposition mr. matthew in bed from supine to a 30 degree side lying position every 2 hours; provides comfort without placing excessive pressure on the greater trochanter
A client's right to give informed consent is based on which ethical principle?
respect for autonomy
during breath sound auscultation of patient being mechanically ventilated, nurse hears coarse snoring sounds over the upper anterior chest with clear sounds over the other lung fields. What should be implemented?
suction the client's et tube
parents of 4 week old male infant reports child eats well but vomits after feeding. Which assessment should the nurse expect to exhibit if inadequate nutrition?
sunken fontanels
Scientific method
systematic ordered approach to gathering data and solving problems
empty the drain and measure the amount of drainage
the nurse should first empty the drain and measure the drainage, then compress the drain to re-establish suction. Documentation of the findings and notification of the surgeon can then be doen
The ICN also says that nursing care includes:
the promotion of health, prevention of illness, & the care of ill, disabled, & dying.
planning DC teaching for a female with frequent urinary tract infections, in teaching how to prevent
void after intercourse
meds causing photosensitivity
wear long sleeves
Patient has active tuberculosis. Action to prevent spread of infection
wear mask when going into patient's room
A nurse is teaching self-monitoring of blood glucose (SMBG) to a client who has diabetes mellitus. Which of the following instructions should the nurse include? Select all that apply. a. Perform SMBG once daily at bedtime b. Wipe the hand with an alcohol swab c. Hold the hand in a dependent position prior to the puncture d. Place the puncture device perpendicular to the site e. Prick the outer edge of the fingertip for the blood sample
C, D, E
A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? Select all that apply. a. Apply petroleum jelly around and inside the nares b. Remove the nasal cannula during meal times c. Check the position of the nannula frequently d. Report any nasal stuffiness, nausea, or fatigue e. Post "No Smoking" signs in a prominent location
C, D, E
A nurse is discussing the HIPAA Privacy Rule with nurses during new employee orientation. Which of the following information should the nurse include? Select all that apply a. A single electronic records password is provided for nurses on the same unit b. Family members should provide a code prior to receiving client health information c. Communication of client information can occur at the nurses' station d. A client can request a copy of her medical record e. A nurse may photocopy a client's medical record for transfer to another facility
B, C, D, E
A nurse is caring for a patient admitted with a closed head injury. Which action by the nurse is appropriate when providing hygiene for this patient? 1) Avoid bathing the patient 2) Use cool water to bathe 3) Provide care in small intervals 4) Rub briskly when drying
3) Provide care in small intervals
Which of the following indicates a 4 year old has successfully gone through Erikson's stage 3 (Initiative vs. Guilt)? 1) Talks about his parents negatively 2) Asks questions about medical instruments 3) Refrains from hitting his friend 4) Stared blankly while you ask questions
3) Refrains from hitting his friend
Which of the following explains why it is important to have the correct etiology for a nursing diagnosis? The etiology: 1) is the cause of the problem 2) can not always be observed 3) directs nursing care 4) is an inference
3) directs nursing care
A nurse checks a physician's order and notes that a new medication was ordered. The nurse is unfamiliar with the medication. A nurse colleague explains that the medication is an anticoagulant used for postoperative patients with risk for blood clots. The nurse's best action before giving the medication is to: [19] 1. Have the nurse colleague check the dose with her before giving the medication 2. Consult with a pharmacist to obtain knowledge about the purpose of the drug, the action, an the potential side effects 3. Ask the nurse colleague to administer the medication to her patient 4. Administer the medication as prescribed and on time
2
Which action is most important for the nurse to implement when donning sterile gloves? A) Maintain thumb at a ninety degree angle. B) Hold hands with fingers down while gloving. C) Keep gloved hands above the elbows. D) Put the glove on the dominant hand first.
C) Keep gloved hands above the elbows Gloved hands held below waist level are considered unsterile (C). (A and B) are not essential to maintaining asepsis. While it may be helpful to put the glove on the dominant hand first, it is not necessary to ensure asepsis (D).
A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate? Select all that apply. a. Urinary incontinence b. Diarrhea c. Bradypnea d. Orthostatic hypotension e. Nausea
C, D, E
A nurse is performing a head and neck examination for an older adult client. Which of the following age-related findings should the nurse expect? Select all that apply. a. Reddened gums b. Lowered vocal pitch c. Tooth loss d. Glare intolerance e. Thickened eardrums
C, D, E
A nurse is introducing herself to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client? Select all that apply. a. Address the client with the appropriate title and her last name b. Use a mix of open-and closed-ended questions c. Reduce environmental noise d. Have the client complete a printed history form e. Perform the general survey before the examination
B, C, E
A nurse is planning diversionary activities for toddlers on an inpatient unit. Which of the following activities should the nurse include? Select all that apply. a. Building models b. Working with clay c. Filling and emptying containers d. Playing with blocks e. Looking at books
C, D, E
A nurse is preparing the discharge summary for a client who has had knee arthroplasty and is going home. Which of the following information about the client should the nurse include in the discharge summary. Select all that apply. a. Advance directives status b. Follow-up care c. Instructions for diet and medications d. Most recent vital sign data e. Contact information for the home health care agency
B, C, E
What are some patient rights?
To see and copy their health record. To update their health record. To request correction of any mistakes. To get a list of disclosures. To request restrictions on certain uses or disclosures. To choose how to receive health information
2 concepts of "knowing the patient" a. b.
a. a nurse's understanding of a specific event b. a nurse's subsequent selection of interventions
Confidence
speak with conviction and always be prepared to perform care safely
In informatics, raw, unprocessed numbers, symbols, or words that have no meaning by themselves are called _______: 1) information 2) data 3) knowledge 4) wisdom
2) Data
A patient is being discharged today. In preparation the nurse removes the IV line from the right arm and documents that the site was "clean and dry with no signs of redness or tenderness." On discharge the nurse reviews the care plan for goals met. Which of the following goals can be evaluated with what you know about this patient? [20] 1. Patient expresses acceptance of health status by day of discharge 2. Patient's surgical would will remain free of infection 3. Patient's IV site will remain free of phlebitis 4. Patient understands when to call physician to report possible complications
3
A nurse is caring for an 82-year-old client in the emergency department who has an oral body temperature of 38.3 degrees C (101 degrees F), pulse rate 114/min, and respiratory rate 22/min. He is restless and his skin is warm. Which of the following interventions should the nurse take. Select all that apply. a. Obtain culture specimens before initiating antimicrobials b. Restrict the client's oral fluid intake c. Encourage the client to rest and limit activity d. Allow the client to shiver to dispel excess heat e. Assist the client with oral hygiene frequently
A, C, E
A nurse educator is presenting a module on basic first aid for newly licensed home heath nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea
A. Hypotension
The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next?
Re-oxygenate the client before attempting to suction again.
What information should the nurse include in the teaching plan of a client who is beginning to take prescription drug Atabuse (disulfiram)
Read labels of over the counter drugs carefully
A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stoke will have which of the following? a. Hypotension b. Bradycardia c. Clammy skin d. Bradypnea
a. Hypotension
A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take? a. Check to see whether the catheter is patent b. Reassure the client that it is not possible for her to urinate c. Recatheterize the bladder with a large-gauge catheter d. Collect a urine specimen for analysis
a. Check to see whether the catheter is patent
A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? a. Complete a fall-risk assessment b. Educate the client and family about fall risks c. Eliminate safety hazards from the client's environment d. Make sure the client uses assistive aids in his possession
a. Complete a fall-risk assessment
Errors in the diagnostic statement:
wrong label, evidence exists for another diagnosis, collaborative problem, failure to validate with the patient, failure to seek guidance
A nurse is caring for a client who has left-sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situation role change based on physical limitations. The client is the primary wage earner in the family. Which of the following describes the client's role problem? a. Role conflict b. Role overload c. Role ambiguity d. Role strain
a. Role conflict
A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time? a. Obtain a walker for the client to use to transfer back to bed b. Call for additional staff to assist with the transfer c. Use a transfer belt and assist the client back into bed d. Determine the client's ability to help with the transfer
d. Determine the client's ability to help with the transfer
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 c. Brush the client's teeth once per day d. Inject a mouth rise into the center of the client's mouth
a. Turn the client's head to the side
A nurse is teaching an adult client how to administer ear drops. Which of the following statements should the nurse identify as an indication that the client understands the proper technique? a. "I will straighten my ear canal by pulling my ear down and back." b. "I will gently apply pressure with my finger to the front part of my ear after putting in the drops." c. "I will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in." d. "After the drops are in, I will place a cotton ball all the way into my ear canal."
b. "I will gently apply pressure with my finger to the front part of my ear after putting in the drops."
A nurse is demonstrating how to insert a IV catheter. Which of the following statements by a nurse viewing the demonstration indicates understanding of the procedure? a. "I will thread the needle all the way into the vein until the hub rests against the insertion site after I see a flashback of blood." b. "I will insert the needle into the client's skin at an angle of 10 to 30 degrees with the bevel up." c. "I will apply pressure approximately 1.2 inches below the insertion site prior to removing the needle" d. "I will choose a vein in the antecubital fossa for IV insertion due to its size and easily accessible location."
b. "I will insert the needle into the client's skin at an angle of 10 to 30 degrees with the bevel up."
A nurse is teaching a group of clients how to care for their colostomies. Which of the following statements should alert the nurse that one of the clients is having an issue with self-concept? a. "I was having difficulty with attaching the appliance at first but my wife was able to help." b. "I'll never be able to care for this at home. Can't you just send a nurse to the house?" c. "I met a neighbor who also has a colostomy, and he taught me a few things." d. "It may take me a while to get the hang of this. I have to admit, I am pretty nervous."
b. "I'll never be able to care for this at home. Can't you just send a nurse to the house?"
A nurse is talking with a patient who is concerned about several issues with her preschooler. Which of the following issues should the nurse identify as the priority? a. "My son mimics my husband getting dressed." b. "My son has temper tantrums every time we tell him to do something he doesn't want to do." c. "I think my son truly believes that his toys have personalities and talk to him." d. "I feel bad when i see my son trying so hard to button his shirt."
b. "My son has temper tantrums every time we tell him to do something he doesn't want to do."
A nurse is evaluating how well a client learned the information he presented in an instructional session about following a heart-healthy diet. The client states that she understands what to do now. Which of the following actions should the nurse take to evaluate the client's learning? a. Encourage the client to ask questions b. Ask the client to explain how to select or prepare meals c. Encourage the client to fill out an evaluation form d. Ask the client if she has resources for further instruction on this topic
b. Ask the client to explain how to select or prepare meals
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? a. Increase the oxygen flow b. Assist the client to Fowler's position c. Promote removal of pulmonary secretions d. Obtain a specimen for arterial blood gases
b. Assist the client to Fowler's position
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. Brush the dentures with a toothbrush and denture cleaner
A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? a. Auscultate breath sounds b. Stop the feeding c. Obtain a chest x-ray d. Initiate oxygen therapy
b. Stop the feeding
After establishing priorities, the nurse should take which action next in developing plan of care a. analyze data b. establish goals c. complete an assessment d. implement interventions
b. establish goals the nurse should first complete the assessment, then analyze the assessed data to identify problems, and then establish goals. After the goals and expected outcomes are established the nurse plans and implements the interventions, which are then evaluated to determine if the expected outcomes and goals were accomplished
Since Florence Nightingale, nursing has . . .
broadened in all areas.
When nurse auscultates anterior chest just above the right nipple, moderate pitched breath sounds heard equal on inspiration and exhalation. Which statement best describes the findings?
bronchovesicular that are normal in that location
most common adverse effect of opiod
constipation
patient who has anxiety and an exacerbation of asthma-primary reason for the nurse to carefully inspect the chest wall of this patient
evaluate the use of intercostal muscles
assessing reddened area
measure the diameter of redness apply light pressure to the area with fingertips
patient is vomiting and restless, diarrhea, respiration rate of 8 to 10 per minute, shows arhythmias on EKG monitor
metabolic alkalosis
patient with metastatic lung cancer and a 60 pack per day history of cigarettes
mucociliary clearance
patient diagnosed with pernicious anemia requires vitamian b12 replacement therapy
patient should schedule daily rest periods to minimize fatigue
Environmental history
patient's home and work, focusing on determining the patient's safety
clinical sign which indicates possible DVT
positive Homan's sign
After gastric surgery a client has a nasogastric tube in place. What should the nurse do when caring for this client? 1 Monitor for signs of electrolyte imbalance. 2 Change the tube at least once every 48 hours. 3 Connect the nasogastric tube to high continuous suction. 4 Assess placement by injecting 10 mL of water into the tube
1 Gastric secretions, which are electrolyte rich, are lost through the nasogastric tube; the imbalances that result can be life threatening. Changing the nasogastric tube every 48 hours is unnecessary and can damage the suture line. High continuous suction can cause trauma to the suture line. Injecting 10 mL of water into the nasogastric tube to test for placement is unsafe; if respiratory intubation has occurred aspiration will result
A nurse administers an intravenous solution of 0.45% sodium chloride. In what category of fluids does this solution belong? 1 Isotonic 2 Isomeric 3 Hypotonic 4 Hypertonic
1 Hypotonic solutions are less concentrated (contain less than 0.85 g of sodium chloride in each 100 mL) than body fluids. Isotonic solutions are those that cause no change in the cellular volume or pressure, because their concentration is equivalent to that of body fluid. This relates to two compounds that possess the same molecular formula but that differ in their properties or in the position of atoms in the molecules (isomers). Hypertonic solutions contain more than 0.85 g of solute in each 100 mL.
After giving a client the nursing diagnosis of Risk for Falls related to Alzheimer's disease, you write an individualized goal to address this diagnosis. Which of the following would be the most appropriate goal for this client? 1) Client will not experience a fall while in the hospital. 2) Client will explain several strategies for preventing falls while in the hospital. 3) Client will demonstrate clear and focused thinking and thus will avoid falling while in the hospital. 4) Client will be able to move independently around her room without falling.
1) Client will not experience a fall while in the hospital.
The physician orders an indwelling urinary catheter for a client who is mildly confused and has been combative. How should the nurse proceed? 1) Ask a colleague to help, because the nurse cannot safely perform the procedure alone. 2) Gather the equipment and prepare it before informing the client about the procedure. 3) Obtain an order to restrian the client before inserting the urinary catheter. 4) Inform the physician that she cannot perform the procedure because the client is confused.
1) Ask a colleague to help, because the nurse cannot safely perform the procedure alone. Asking a colleague for help with a confused and combative patient because of safety issues in doing the procedure alone.
You are caring for a client who is confined to bed following back surgery. Which of the following measures should you take to promote normal bowel elimination in this client? SELECT ALL THAT APPLY. 1) Assist the client into a semi-Fowler's position to use the bedpan. 2) Encourage the client to defecate soon after she feels the urge to do so. 3) Encourage the client to drink eight to ten 8-ounce glasses of water daily. 4) Perform range-of-motion (ROM) exercises with the client to promote peristalsis. 5) Encourage the client to eat foods rich in protein, such as red meat. 6) Stand by the client while she defecates to provide encouragement.
1) Assist the client into a semi-Fowler's position to use the bedpan. 2) Encourage the client to defecate soon after she feels the urge to do so. 3) Encourage the client to drink eight to ten 8-ounce glasses of water daily. 4) Perform range-of-motion (ROM) exercises with the client to promote peristalsis.
List the 5 steps of the nursing process (a-e)
a. assessment b. diagnosis c. planning d. interventions e. evaluations
Dependent nursing interventions
are physician initiated interventions that require an order from a physician or other HCP
You are providing safety promotion counseling to the mother of a 2-year-old. Which of the following should you warn her is the leading cause of death in children her child's age? 1) Motor vehicle accidents2) Drowning3) Poisoning4) Homicide
2) Drowning
When you ask an older client about his urinary health, he admits to you that he cannot always get to the restroom in time to urinate because of his impaired mobility and use of a walker. Which type of incontinence is this an example of? 1) Urge incontinence 2) Functional incontinence 3) Stress incontinence 4) Reflex incontinence
2) Functional incontinence
Which medication will the physician most likely prescribe to increase urine output for patient with CHF? 1) Digoxin 2) Furosemide 3) Lovastatin 4) Atorvastatin
2) Furosemide
A patient is taking albuterol through a pressurized metered-dose inhaler that contains a total of 200 puffs. The patient takes 2 puffs every 4 hours. How many days will the inhaler last? [31] _______ days.
16
A patient is having difficulty with feelings of self-loathing and disgust after being attacked and raped. According to Maslow, which level is the patient struggling with? 1) Physiological 2) Safety & Security 3) Love & Belonging 4) Self-esteem
4) Self-esteem Self-hatred & disgust is opposite of what one would expect in the self-esteem level of Maslow's model.
You are instructing a client to actively move his arm through its full range of motion. Which division of the client's nervous system is allowing him to move his arm in this way? 1) Autonomic 2) Sympathetic 3) Parasympathetic 4) Somatic
4) Somatic
An IV infusion terbutaline sulfate 5 mg in 500 ml of D5W, is infusing at a rate of 30 mcg/min prescribed for a client in premature labor. How many ml/hr should the nurse set the infusion pump?
180
When a nurse is performing surgical hand asepsis, the nurse must keep hands: [28] 1. Below elbows 2. Above elbows 3. At a 45-degree angle 4. In a comfortable position
2
You are counseling a client with osteoarthritis about possible exercise programs suited to her needs. Which of the following types of exercise would be best for her? 1) Resistance training with free weights 2) Jogging 3) Soccer 4) Swimming
4) Swimming
A nurse check a patient's IV line in his right arm and sees inflammation where the catheter enters the skin. She uses her finger to apply light pressure (i.e., palpation) just above the IV site. The patient tells her the area is tender. The nurse checks to see if the IV line is running at the correct rate. This is an example of which type of assessment? [16] 1. Agenda setting 2. Problem-focused 3. Objective 4. Use of structured database format
2
A client who is suspected of having tetanus asks a nurse about immunizations against tetanus. Before responding, what should the nurse consider about the benefits of tetanus antitoxin? 1 It stimulates plasma cells directly. 2 A high titer of antibodies is generated. 3 It provides immediate active immunity. 4
2 A long-lasting passive immunity is produced. Tetanus antitoxin provides antibodies, which confer immediate passive immunity. Antitoxin does not stimulate production of antibodies. It provides passive, not active, immunity. Passive immunity, by definition, is not long-lasting.
You are conversing with a 13-year-old client while reviewing his health history before a physical examination. The client mentions to you that he went shooting with his father last weekend. After listening to his story, you ask him whether he knows the rules for safe gun handling. He stammers a minute and then tells you he can't remember them. Which of the following rules should you tell him? SELECT ALL THAT APPLY. 1) Keep your finger on the trigger until you are ready to shoot. 2) Always keep the gun pointed in a safe direction. 3) Assume that a gun is unloaded until you have checked the chamber. 4) Always keep the gun unloaded until ready to use it. 5) Before cleaning a gun make sure that it is loaded. 6) If you do not know how to open the gun and inspect the chamber or chambers, leave it alone and get help from someone who does.
2) Always keep the gun pointed in a safe direction. 4) Always keep the gun unloaded until ready to use it. 6) If you do not know how to open the gun and inspect the chamber or chambers, leave it alone and get help from someone who does.
The nurse has redressed a patient's wound and now plans to administer a medication to the patient. Which is the correct infection control procedure? [28] 1. Leave the gloves on to administer the medication 2. Remove gloves and administer the medication 3. Remove gloves and perform hand hygiene before administering the medication 4. Leave the medication on the bedside table to avoid having to remove gloves before leaving the patient's room
3
A nurse is talking with the parents of a 6-month-old infant about gross motor development. Which of the following gross motor skills are expected findings in the next 3 months? Select all that apply. a. Rolls from back to front b. Bears weight on legs c. Walks holding onto furniture d. Sits unsupported e. Sits down from a standing position
A, B, D
A nurse reviews data gathered regarding a patient's pain symptoms. The nurse compares the defining characteristics for acute pain with those for chronic pain and in the end selects acute pain as the correct diagnosis. This is example of the nurse avoiding an error in: [17] 1. data collection 2. data clustering 3. data interpretation 4. making a diagnostic statment
3
You are working with a male client who weighs 330 pounds and is 74 inches tall. Which of the following is his body mass index (BMI)? 1) 37.8 2) 39.4 3) 41.6 4) 43.2
3) 41.6
Correct position for a patient walking with a cane
30 degree flexion at the elbow
A nurse is preparing to administer 0.9% sodiumchloride (0.9% NaCl) 250 mL IV to infuse over 30 min. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should adjust the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Do not use a trailing zero).
83 gtt/min
The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min?
83 gtt/min.
A student nurse is designing a health fair project aimed at reducing motor vehicle accidents. For which group of clients would this subject be most appropriate? A) Adolescents B) Older adults C) Middle-aged adults D) School-aged children
A) Adoescents The risk of motor vehicle accidents is higher among teen drivers than in any other age group.
If an infectious disease can be transmitted directly from one person to another, it is: A) A susceptible host B) A communicable disease C) A portal of entry to a host D) A portal of exit from the reservoir
B) A communicable disease If an infectious disease is transmitted directly from one person to another, it is a communicable disease. Portals of entry and exit are the mechanisms of disease transmission. A susceptible host is a person who can acquire an infection.
86.A healthcare provider is performing a sterile procedure at a client's bedside. Near the end of the procedure, the nurse observes the healthcare provider contaminate a sterile glove and the sterile field. What is the best action for the nurse to implement? A. Report the healthcare provider for the violation in aseptic technique. B. Allow the completion of the procedure. C. Ask if the glove and sterile field are contaminated. D. Identify the break in surgical asepsis and provide another set of sterile supplies.
Any possible break in surgical asepsis that is identified when others are unaware should be considered contaminated and new sterile supplies added to maintain the sterile field (D). Reporting the healthcare provider is not indicated (A). When sterility is suspect during aseptic technique, it should not be questioned (C) but all members of the team should move forward with reestablishing a sterile field. Allowing the procedure to progress under unsterile conditions (B) places the client at risk for infection and is an act of omission (negligence) by the nurse and other healthcare team members. Correct Answer: D
A nurse is caring for a client who weighs 80 kg (176 lb) and is 1.6 m (5 ft 3 in) tall. Calculate her body mass index (BMI) and determine whether this client's BMI indicates that she is a health weight, overweight, or obese.
BMI = 31.25 A BMI greater than 30 is considered obese
Which action is most important for the nurse to implement when donning sterile gloves?
Keep gloved hands above the elbows.
Client with Hep. A and dehydration subjective symptoms: fatigue, anorexia. What additional info should be assessed?
RUQ abdominal pain
Heart isnt beating fast enough to circulate O2, atropine
Sinus brady
A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the secondary infusion?
The infusion rate is calculated as a ratio proportion problem, i.e., 50 ml/ 20 min : x ml/ 60 min. Multiply extremes and means 50 × 60 /20x 1= 300/20=150 Correct Answer: 150
Utilitarian =
The rightness or wrongness of an action depends on the consequences of the action.
Carpal spasm induced by BP cuff and seen in patient with hypocalcemia
Trousseau's sign
Perseverance
be cautious of any easy answer; look for a pattern and find a solution
before attaching o2 sat
clean client's finger, remove any nail polish or artificial nails
Define data validation:
comparison of data with another source to determine data accuracy
order of application of PPE
hand hygiene gown mask gloves
patient is asked to take several slow, deep breaths during suppository insertion
relaxes the anal sphincter and reduces discomfort
pneumatic compression devices
used to prevent DVT, improves venous circulation
dehiscence
wound splits open; a 4cm area of dehiscence is observed on abdomen is highest priority
53.A medication is prescribed to be given QID. What schedule should the nurse use to administer this prescription? A. 0800, 1200, 1600, 2000. B. 800. C. Every other day at 0800. D. 0800, 1200, 1600, 2000, 0000, 0400.
(A) provides the best schedule, because QID means four times per day. (B, C, and D) provide incorrect dosages. Correct Answer: A
The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the nurse administer? A. 1 ml. B. 1.5 ml. C. 1.75 ml. D. 2 ml.
(B) is the correct calculation: Dosage on hand/amount on hand = Dosage desired/x amount. 20 mg : 2 ml = 15 mg : x . 20x = 30. x = 30/20; = 1½ or 1.5 ml. Correct Answer: B
A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump? A. 13 ml/hour. B. 63 ml/hour. C. 80 ml/hour. D. 125 ml/hour.
(B) is the correct calculation: To calculate this problem correctly, remember that the dose of KCl is not used in the calculation. 250 ml/4 hours = 63 ml/hour. Correct Answer: B
At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence? A. It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel. B. Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery. C. It is OK if you don't want to talk about your surgery. I will be available when you are ready. D. I will ask a woman who has had a mastectomy to come by and share her experiences with you.
(C) displays sensitivity and understanding without judging the client. (A) is judgmental in that it is telling the client how she feels and is also insensitive. (B) would give the client a chance to talk, but is also demanding and demeaning. (D) displays a positive action, but, because the nurse's personal support is not offered, this response could be interpreted as dismissing the client and avoiding the problem. Correct Answer: C
37.When the nurse enters a client's room to do an initial assessment, the client shouts, "Get out of my room! I'm tired of being bothered!" How should the nurse respond? A. There is no reason to be so angry. B. Why do I need to leave your room? C. What is concerning you this morning? D. Let me call the client advocate for you.
(C) is an open-ended question that encourages the client to discuss personal feelings. (A) devalues the client and hinders further communication. Acting defensively and asking why questions such as (B) are likely to elicit more anger and block communication. By deferring to the client advocate (D), the nurse fails to even address the client's feelings of anger and exasperation. Correct Answer: C
The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to administer? A. ½ tablet. B. 1 tablet. C. 1½ tablets. D. 2 tablets.
(C) is the correct calculation: D/H × Q = 7.5/5 × 1 tablet = 1½ tablets. Correct Answer: C
Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse? A. That means you have derived the maximum benefit, and the heat can be removed. B. Your blood vessels are becoming dilated and removing the heat from the site. C. We will increase the temperature 5 degrees when the pad no longer feels warm. D. The body's receptors adapt over time as they are exposed to heat.
(D) describes thermal adaptation, which occurs 20 to 30 minutes after heat application. (A and B) provide false information. (C) is not based on a knowledge of physiology and is an unsafe action that may harm the client. Correct Answer: D
The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive? A. 31 gtt/min. B. 62 gtt/min. C. 93 gtt/min. D. 124 gtt/min.
(D) is the correct calculation: Convert lbs to kg: 182/2.2 = 82.73 kg. Determine the dosage for this client: 5 mcg × 82.73 = 413.65 mcg/min. Determine how many mcg are contained in 1 ml: 250/50,000 mcg = 200 mcg per ml. The client is to receive 413.65 mcg/min, and there are 200 mcg/ml; so the client is to receive 2.07ml per minute. With a drip factor of 60 gtt/ml, then 60 × 2.07 = 124.28 gtt/min (D) OR, using dimensional analysis: gtt/min = 60 gtt/ml X 250 ml/50 mg X 1 mg/1,000 mcg X 5 mcg/kg/min X 1 kg/2.2 lbs X 182 lbs. Correct Answer: D
The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? A. Place the chair at a right angle to the bed on the client's left side before moving. B. Assist the client to a standing position, then place the right hand on the armrest. C. Have the client place the left foot next to the chair and pivot to the left before sitting. D. Move the chair parallel to the right side of the bed, and stand the client on the right foot.
(D) uses the client's stronger side, the right side, for weight-bearing during the transfer, and is the safest approach to take. (A, B, and C) are unsafe methods of transfer and include the use of poor body mechanics by the caregiver. Correct Answer: D
50.The nurse assesses an immobile, elderly male client and determines that his blood pressure is 138/60, his temperature is 95.8° F, and his output is 100 ml of concentrated urine during the last hour. He has wet-sounding lung sounds, and increased respiratory secretions. Based on these assessment findings, what nursing action is most important for the nurse to implement? A. Administer a PRN antihypertensive prescription. B. Provide the client with an additional blanket. C. Encourage additional fluid intake. D. Turn the client q2h.
(D) will help to move and drain respiratory secretions and prevent pneumonia from occurring, so this intervention has the highest priority. Older adults often have an increased BP, and a PRN antihypertensive medication is usually prescribed for a BP over 140 systolic and 90 diastolic (A). Older adults often run a lower temperature, particularly in the morning, and (B) does not have the priority of (D). Even though the client has adequate output, (C) might be encouraged because the urine is concentrated, but this intervention does not have the priority of (D). Correct Answer: D
patient understood need for a pacer
"more of the medication will get down into my lungs to help my breathing"
Caring in nursing is:
- A way of being, knowing, & doing with the goal of protection, enhancement, & preservation of human dignity. - Action and competencies that aim toward the good and welfare of others.
A nurse is preparing to administer methylprednisolone 10 mg by IV bolus. The amount available is methyprednisolone injection 40 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Do not use a trailing zero).
0.3 mL
A nurse is preparing to administer ketorolac 0.5 mg/kg IV bolus every 6 hr to a school-age child who weighs 66 lb. The amount available is ketorolac injection 30 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero).
0.5 mL
The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the nurse administer?
0.5 ml.
A 62-year-old woman is being discharged home with her husband after surgery for a hip fracture from a fall at home. When providing discharge teaching about home safety to this patient and her husband, the nurse knows that: [27] 1. A safe environment promotes patient activity 2. Assessment focuses on environmental factors only 3. Teaching home safety is a difficult to do in the hospital setting 4. Most accidents in the older adult are caused by lifestyle factors
1
A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid in the IV line, and the patient asking to be turned. Which of the following does the nurse perform first? [18] 1. Reconnect the drainage tube 2. Inspect the condition of the IV dressing 3. Improve the patient's comfort and turn her onto her side 4. Obtain the next IV fluid bag from the medication room
1
A patient who visits the allergy clinic tells the nurse practitioner that he is not getting relief from shortness of breath when he uses his inhaler. The nurse decides to ask the patient to explain how he uses his inhaler, when he should take a dose of medication, and what he does when he gets no relief. On the basis of Gordon's functional health patterns, which pattern does the nurse assess? [16] 1. Health perception- health management pattern 2. Value-belief pattern 3. Cognitive-perceptual pattern 4. Coping-stress tolerance pattern
1
At 3am the emergency department nurse hears that a tornado hit the east side of town. What action does the nurse take first? [27] 1. Prepare for an influx of patients 2. Contact the American Red Cross 3. Determine how to restore essential services 4. Evacuate patients per the disaster plan
1
Before consulting with a physician about a patient's need for urinary catheterization, the nurse considers the fact that the patient has urinary retention and has been unable to void on her own. The nurse knows that evidence for alternative measures to promote voiding exist, but none has been effective, and that before surgery the patient was voiding normally. This scenario is an example of which implementation skill? [19] 1. Cognitive 2. Interpersonal 3. Psychomotor 4. Consultative
1
The following nursing diagnoses all apply to one patient. As the nurse adds these diagnoses to the care plan, which diagnoses will not include defining characteristics? [17] 1. Risk for aspiration 2. Acute confusion 3. Readiness for enhanced coping 4. Sedentary lifestyle
1
The nurse is administering a sustained-release capsule to a new patient. The patient insists that he cannot swallow pills. What is the nurse's best course of action? [31] 1. Ask the prescriber to change the order 2. Crush the pill with a mortar and pestle 3. Hide the capsule in a piece of solid food 4. Open the capsule and sprinkle it over pudding
1
The nurse takes a medication to a patient, and the patient tells him or her to take it way because she is not going to take it. What is the nurse's next action? [31] 1. Ask the patient's reason for refusal 2. Explain that she must take the medication 3. Take the medication away and chart the patient's refusal 4. Tell the patient that her physician knows what's best for her
1
The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: [27] 1. Place a bed alarm device on the bed 2. Place the patient in a belt restraint 3. Provide one-on-one observation of the patient 4. Apply wrist restraints
1
Which of the following is the most effective way to break the chain of infection? [28] 1. Hand hygiene 2. Wearing gloves 3. Placing patients in isolation 4. Providing private rooms for patients
1
You are floated to work on a nursing unit where you are given an assignment that is beyond your capability. What is the best nursing action to take first? [23] 1. Call the nursing supervisor to discuss the situation 2. Discuss the problem with a colleague 3. Leave the nursing unit and go home 4. Say nothing and begin your work
1
Your ungloved hands come in contact with the drainage from your patient's wound. What is the correct method to clean your hands? [28] 1. Wash them with soap and water 2. Use an alcohol-based hand cleaner 3. Rinse them and use the alcohol-based cleaner 4. Wipe them with a paper towel
1
A nurse who is working on a medical-surgical unit receives a phone call requesting information about a client who has undergone surgery. The nurse observes that the client requested a do not publish (DNP) order on any information regarding condition or presence in the hospital. What is the best response by the nurse? 1 "We have no record of that client on our unit. Thank you for calling." 2 "The new privacy laws prevent me from providing any client information over the phone." 3 "The client has requested that no information be given out. You'll need to call the client directly." 4 "It is against the hospital's policy to provide you with any information regarding any of our clients."
1 The response "We have no record of that client on our unit. Thank you for calling." conforms to the request that no information be given regarding the client's condition or presence in the hospital. HIPAA laws do not prohibit the provision of information to others as long as the client consents. The response "The client has requested that no information be given out. You'll need to call the client directly." implies that the client is admitted to the facility; this violates the client's request that no information should be shared with others. Hospital policies do not prohibit the provision of information to others as long as the client consents. The response "It is against the hospital's policy to provide you with any information regarding any of our clients." also implies that the client is admitted to the facility.
What should the nurse consider when obtaining an informed consent from a 17-year-old adolescent? 1 If the client is allowed to give consent 2 The client cannot make informed decisions about health care. 3 If the client is permitted to give voluntary consent when parents are not available 4 The client probably will be unable to choose between alternatives when asked to consent
1 A person is legally unable to sign a consent until the age of 18 years unless the client is an emancipated minor or married. The nurse must determine the legal status of the adolescent. Although the adolescent may be capable of intelligent choices, 18 is the legal age of consent unless the client is emancipated or married. Parents or guardians are legally responsible under all circumstances unless the adolescent is an emancipated minor or married. Adolescents have the capacity to choose, but not the legal right in this situation unless they are legally emancipated or married.
Health promotion efforts with the chronically ill client should include interventions related to primary prevention. What should this include? 1 Encouraging daily physical exercise 2 Performing yearly physical examinations 3 Providing hypertension screening programs 4 Teaching a person with diabetes how to prevent complications
1 Primary prevention activities are directed toward promoting healthful lifestyles and increasing the level of well-being. Performing yearly physical examinations is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Providing hypertension screening programs is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Teaching a person with diabetes how to prevent complications is a tertiary prevention. Emphasis is on rehabilitating individuals and restoring them to an optimum level of functioning.
A client is taking lithium sodium (Lithium). The nurse should notify the health care provider for which of the following laboratory values? 1 White blood cell (WBC) count of 15,000 mm3 2 Negative protein in the urine 3 Blood urea nitrogen (BUN) of 20 mg/dL 4 Prothrombin of 12.0 seconds
1 White cell counts can increase with this drug. The expected range of the WBC count is 5000 to 10,000 mm3 for a healthy adult. Urinalysis, BUN, and prothrombin are not necessary and these are normal values.
You are working with a male client who weighs 275 pounds. Using the formula provided in your text, which of the following is his basal metabolic rate in kilocalories (kcal) per day (24 hours)? 1) 3,000 2) 2,800 3) 2,600 4) 2,400
1) 3,000
The nurse and nursing assistive personnel (NAP) are caring for a group of patients on the med-surg floor. For which of the following patients can the nurse delegate to the NAP the task of bathing? Choose all that apply. 1) 75 year old patient newly admitted with dehydration 2) 65 year old patient hospitalized for a stroke whose BP is 189/90 3) 92 year old patient with stable vital signs who was admitted with a UTI 4) 56 year old patient with chronic renal failure who has VS within his normal range.
1) 75 year old patient newly admitted with dehydration 3) 92 year old patient with stable vital signs who was admitted with a UTI 4) 56 year old patient with chronic renal failure who has VS within his normal range. A 65 year old who suffered a stroke and has high BP would not be appropriate for the CNA to bathe themselves.
As you see various clients throughout the day, you encourage those who are at high risk for pneumonia to be immunized. Which of the following are examples of clients who should be immunized? SELECT ALL THAT APPLY. 1) A 68-year-old in excellent health 2) A 3-year-old who occasionally develops ear infections 3) A 25-year-old with alcoholism 4) A 42-year-old with no chronic diseases 5) A 20-year-old with asthma 6) A 10-year-old with seasonal allergies
1) A 68-year-old in excellent health 2) A 3-year-old who occasionally develops ear infections 3) A 25-year-old with alcoholism 5) A 20-year-old with asthma
You are using the MyPlate food guide to provide nutritional teaching to a client. Which of the following points from this food guide should you emphasize with the client? SELECT ALL THAT APPLY. 1) Balance calories by avoiding oversize portions. 2) Choose 2% milk to decrease the amount of fat and number of calories. 3) Make sure that 50% of each meal is composed of fruits and vegetables. 4) Eat protein only two or three times each week. 5) Engage in exercise in addition to eating well. 6) Cut back on whole grains.
1) Balance calories by avoiding oversize portions. 3) Make sure that 50% of each meal is composed of fruits and vegetables. 5) Engage in exercise in addition to eating well.
You are caring for a client who has a dislocated shoulder. Which type of synovial joint is the shoulder? 1) Ball-and-socket 2) Condyloid 3) Hinge 4) Pivot
1) Ball-and-socket
You are caring for a client who is on mechanical ventilation. Which of the following interventions should you perform? SELECT ALL THAT APPLY. 1) Check arterial blood gases and assess respiratory status about 30 minutes after setup. 2) Maintain the patient in a recumbent position (head of the bed all the way down). 3) Drain the condensate from the ventilator tubing into the humidifier. 4) Give sedatives or anti-anxiety drugs as needed. 5) Reposition the patient every 1 to 2 hours. 6) Moisten the lips with a cool, damp cloth and water-based lubricant.
1) Check arterial blood gases and assess respiratory status about 30 minutes after setup. 4) Give sedatives or anti-anxiety drugs as needed. 5) Reposition the patient every 1 to 2 hours. 6) Moisten the lips with a cool, damp cloth and water-based lubricant.
In his later work, Maslow identified growth needs that must be met before reaching self-actualization. These needs include: 1) Cognitive and aesthetic 2) Love and belonging 3) Safety and Security 4) Physiological and Self-esteem
1) Cognitive and aesthetic needs
A family assessment should include the following areas: (choose all that apply) 1) Coping patterns 2) Health beliefs 3) Medical history 4) Physical exam
1) Coping patterns 2) Health beliefs Medical history and physical exams are only relevant to the family assessment if it affects other family members.
Which statement(s) about culture is/are true? Choose all that apply. 1) Culture exists on both material and nonmaterial levels 2) Culture mainly influences food choices and special holidays 3) Cultural customs change over time at different rates 4) Culture is learned through life experiences shared by other cultural members.
1) Culture exists on both material and nonmaterial levels 3) Cultural customs change over time at different rates 4) Culture is learned through life experiences shared by other cultural members.
The nurse should encourage a group of teenagers to eat plenty of _______________? 1) Dairy products 2) Fish 3) Nuts & Legumes 4) High fiber products
1) Dairy products Dairy products help build up calcium in growing bodies.
A nurse is caring for an 80 year old patient of Chinese heritage. When planning outcomes for this patient, which actions by the nurse would meet the American Nurses Association standards for outcomes identification? Choose all that apply. 1) Developing culturally appropriate outcomes 2) Using the outcomes preprinted on the clinical pathway 3) Doing whatever it takes for the patient, no matter the cost 4) Involving the patient and family in formulating outcomes
1) Developing culturally appropriate outcomes 4) Involving the patient and family in formulating outcomes
Which statement best describes theology? 1) Discussions and theories related to God and His relation to the world 2) Doctrines about the human soul and its relation to eternal life 3) A life-long journey involving accumulation of experience and understanding 4) Codes of ethics that integrate beliefs and values.
1) Discussions and theories related to God and His relation to the world Discussions and theories related to God and his relation to the world
The nurse should assess skin temperature by using the: 1) dorsum of the hand 2) pad of the fingertip 3) palm of the hand 4) dorsum of the wrist
1) Dorsum of the hand
Which of the following is the flap of connective tissue that closes over the trachea when food is swallowed to prevent choking and aspiration? 1) Epiglottis 2) Gastroesophageal sphincter 3) Ileocecal valve 4) Duodenum
1) Epiglottis
You are providing nutritional counseling to a high school student who decided to stop eating meat a year ago and who has now developed anemia. You explain to the client that it is important for him to consume adequate protein from non-meat sources because this nutrient performs many critical functions in the body. These functions include which of the following? SELECT ALL THAT APPLY. 1) Facilitates growth, maintenance, and repair of body cells and tissues 2) Forms hemoglobin, the oxygen carrier in red blood cells 3) Provides insulation 4) Protects vital organs 5) Defends against foreign invaders in the form of lymphocytes and antibodies 6) Enables accurate nerve-impulse transmission
1) Facilitates growth, maintenance, and repair of body cells and tissues 2) Forms hemoglobin, the oxygen carrier in red blood cells 5) Defends against foreign invaders in the form of lymphocytes and antibodies
Which of the following are functions of the kidneys? SELECT ALL THAT APPLY. 1) Filter metabolic wastes from the bloodstream and excrete them as urine 2) Transport urine to the bladder 3) Regulate blood volume 4) Store urine until it is discharged from the body 5) Regulate electrolyte levels 6) Produce erythropoietin
1) Filter metabolic wastes from the bloodstream and excrete them as urine 3) Regulate blood volume 5) Regulate electrolyte levels 6) Produce erythropoietin
You are teaching a client about how to establish a healthy and effective exercise program. Which of the following should you do? SELECT ALL THAT APPLY. 1) Find out what fitness goals motivate your client. 2) Help the client set personal goals for physical activity. 3) Recommend that the client stick to one activity, to promote discipline. 4) Warn your client that exercise is difficult and that he might not be able to maintain his program. 5) Encourage the client to find physical activities that are enjoyable to him. 6) Discuss barriers to regular activity and ways to overcome these barriers.
1) Find out what fitness goals motivate your client. 2) Help the client set personal goals for physical activity. 5) Encourage the client to find physical activities that are enjoyable to him. 6) Discuss barriers to regular activity and ways to overcome these barriers.
A client has mentioned that she would like to begin an exercise program that includes cycling and weight lifting. You mention that she should also include exercise that warms the muscles before activity, cools them afterward, limits post-exercise stiffness, and keeps joints mobile. Which type of exercise are you recommending for this client? 1) Flexibility training 2) Resistance training 3) Aerobic conditioning 4) Anaerobic conditioning
1) Flexibility training
You are caring for a client who is experiencing short-term constipation while in the hospital recovering from surgery. Which of the following interventions should you make to treat this condition? SELECT ALL THAT APPLY. 1) Increase the client's intake of fruits and vegetables. 2) Increase fluid intake. 3) Decrease physical activity. 4) Assist the client into a side-lying position whenever possible. 5) Allow the client 5 minutes following a meal to use the toilet. 6) Assess for hemorrhoids.
1) Increase the client's intake of fruits and vegetables. 2) Increase fluid intake. 6) Assess for hemorrhoids.
What is the body's first line of defense against bacteria? 1) intact skin 2) hair 3) immune system 4) lymph glands
1) Intact skin
You are caring for a client who recently experienced a spinal cord injury and is now paralyzed from the waist down. Which type of catheterization will this client likely require? 1) Intermittent self-catheterization with a straight catheter 2) Continuous bladder drainage with an indwelling catheter 3) Continuous bladder drainage with a suprapubic catheter 4) Intermittent self-catheterization with a Foley catheter
1) Intermittent self-catheterization with a straight catheter
You have decided that as a last resort you must apply physical restraints to a client who is at risk of injuring himself and healthcare team members. Which of the following actions must you take? SELECT ALL THAT APPLY. 1) Obtain a medical order before restraining. 2) Secure restraints in a way that allows for quick release. 3) Check restraints every 2 hours. 4) Remind prescriber to reassess and reorder the restraints every week, as needed. 5) Ensure that the restraints do not impair circulation or tissue integrity. 6) Release restraints and assess every 8 hours.
1) Obtain a medical order before restraining. 2) Secure restraints in a way that allows for quick release. 5) Ensure that the restraints do not impair circulation or tissue integrity.
You are caring for a client who is experiencing fecal impaction. You are planning on administering a cleansing enema to evacuate the intestine of stool, but first you would like to administer a retention enema to soften the hard stool and lubricate the rectum. Which of the following types of retention enema should you use? 1) Oil-retention enema 2) Carminative enema 3) Medicated enema 4) Nutritive enema
1) Oil-retention enema
Following allergy testing with a child, you find that she is allergic to cockroaches. This finding means that the child is at greater risk for which of the following? 1) Severe asthma 2) Rabies 3) Lung cancer 4) Fungal infection
1) Severe asthma
Which healthcare worker should the nurse counsel a patient about financial and family stressors impacting healthcare? 1) Social worker 2) Occupational therapy 3) Physician's assistant 4) Charge nurse
1) Social worker The social worker coordinates services and counsels patients about financial, housing, marital, and family issues.
In performing a hand-off report, the nurse should communicate information on: (select all that apply) 1) Teaching performed 2) Any change in client status 3) Treatments administered 4) Hygiene measures performed
1) Teaching performed 2) Any change in client status 3) Treatments administered
You are teaching a client how to use a peak flow meter at home. Which of the following instructions is accurate? 1) The client should take a deep breath and forcefully exhale. 2) The client should take a series of three readings and record the average. 3) The client should maintain or adjust medication according to the lowest reading. 4) The client's current reading should be compared against the national average reading.
1) The client should take a deep breath and forcefully exhale.
While caring for a client in the hospital, you observe that she has to get up several times during the night to urinate. As you investigate this, you first conduct a nursing history with the client. What is the best rationale for taking a nursing history in this case? 1) This urination pattern might be normal for the client. 2) The underlying urinary problem might be genetic. 3) The underlying urinary problem might be the result of recent trauma. 4) This urination pattern might reflect a psychological disturbance.
1) This urination pattern might be normal for the client.
A community health nurse wants to provide health promotion classes through the local hospital, which of the following topics might be included in this endeavor? Select all that apply. 1) Time Management 2) Healthy eating habits 3) Exercise after a stroke 4) Bicycle safety for children
1) Time Management 2) Healthy eating habits 4) Bicycle safety for children Teaching exercise after a stroke focuses more on rehabilitation.
You are caring for a client with chronic obstructive pulmonary disease (COPD) who is short of breath. Which of the following positions would be best for this client? 1) Tripod, leaning on an overbed table 2) Semi-Fowler's 3) Side lying with pillows to support the upper arm 4) Supine, with the knees bent
1) Tripod, leaning on an overbed table
A patient takes anticoagulants. Which is the most important for the nurse to include on the patient's care plan? Teach the patient to: 1) Use an electric razor for shaving 2) Apply skin moisture 3) Use less soap 4) Floss teeth daily
1) Use an electric razor Use an electric razor instead of a double edged razor for shaving to reduce the risk of excess bleeding.
You are caring for an older patient in the hospital who is at risk for falling. The client is cognitively normal but lacks coordination. Which of the following are interventions you should take to help prevent the client from falling? SELECT ALL THAT APPLY. 1) Use quarter-length siderails on the patient's bed. 2) Keep the bed in a low position. 3) Provide nonskid slippers. 4) Keep water, urinal, bedpan, and tissues out of reach so that the patient must have assistance to get them. 5) Encourage the patient to move to and from the bathroom independently, to build confidence. 6) Provide a night light
1) Use quarter-length siderails on the patient's bed. 2) Keep the bed in a low position. 3) Provide nonskid slippers. 6) Provide a night light
Alcohol-based solutions for hand hygiene can be used to combat which types of organisms? Select all that apply. 1) Virus 2) Bacterial Spores 3) Yeast 4) Mold
1) Virus 3) Yeast 4) Mold Alcohol-based solutions are ineffective against bacterial spores.
Which of the following nursing activities is of highest priority for maintaining medical asepsis? 1) Washing hands 2) Donning gloves 3) Wearing a gown 4) Wearing a face mask
1) Washing hands Hand washing is the most important part of medical asepsis
A patient suddenly develops right lower quadrant pain, nausea, vomiting. How should the nurse classify this patient? 1) Acute 2) Chronic 3) Intralatable 4) neuropathic
1) acute
6 factors the nurse uses to select nursing interventions for a specific patient:
1) desired patient outcomes 2) characteristics of the nursing diagnosis 3) research base knowledge for the interventions 4) feasibility for doing the intervention 5) acceptability to the patient 6) your own competency
Which of the following reflects understanding of the characteristics of older adults? 1) Fewer than 5% of older adults live in nursing homes. 2) Average life expectancy has declined in the past 10 years. 3) In general, men live longer than women. 4) Black men have the lowest life expectancy.
1) fewer than 5% of older adults live in nursing homes. Only 3.3% of people 65 years and older live in nursing homes.
List Gordon's 11 functional health patterns:
1) health perception-health management pattern 2) nutritional-metabolic pattern 3) elimination pattern 4) activity-exercise pattern 5) sleep-rest pattern 6) cognitive-perceptual pattern 7) self-perception - self-concept pattern 8) role-relationship pattern 9) sexuality-reproductive pattern 10) coping-stress pattern 11) value-belief pattern
6 Steps to the nurse's role when seeking consultation
1) identify the general problem area 2) direct the consultation to the right professional 3) provide the consultant with relevant information about the problem area 4) do not prejudice or influence the consultants 5) be available to discuss the findings and recommendations 6) incorporate the recommendations into the plan of care
Which of the following terms refers to the ethics questions that arise out of nursing practice? 1) nursing ethics 2) bioethics 3) ethical dillema 4) moral distress
1) nursing ethics
Which of the following contributions of Florence Nightingale had an immediate impact on improving patient's health? 1) Providing a clean environment 2) Improving nursing education 3) Changing the delivery of care in hospitals 4) establishing nursing as a distinct profession
1) providing a clean environment Improved sanitation greatly and immediately reduced the rate of infection and mortality in hospitals.
Which of the following health information is protected in electronic health records? choose all that apply. 1) social security number 2) insurance information 3) physicians name 4) lab results
1) social security number 2) insurance information 4) lab results
Which of the following informatics concept concerns the appropriate use of knowledge in managing or solving human problems? 1) wisdom 2) knowledge 3) data 4) information
1) wisdom
A new graduate nurse is being mentored by a more experienced nurse. They are discussing the ways nurses need to remain active professionally. Which of the statements below indicates the new graduate understands ways to remain involved professionally? (Select all that apply) [23] 1. "I am thinking about joining the health committee at my church." 2. "I need to read newspapers, watch news broadcasts, and search the Internet for information related to health." 3. "I will join nursing committees at the hospital after I have several years of experience and better understand the issues affecting nursing." 4. "Nurses do not have very much voice in legislation in Washington, D.C. because of the shortage of nurses."
1, 2
A nurse is starting on the evening shift and is assigned to care for a patient with a diagnosis of "impaired skin integrity related to pressure and moisture on skin." The patient is 72-years-old and had a stroke. The weighs 250 pounds and is difficult to turn. As the nurse makes decisions about how to implement skin care for the patient, which of the following actions does the nurse implement? (Select all that apply) [19] 1. Review the set of all possible nursing interventions for the patient's problem 2. Review all possible consequences associated with each possible nursing action 3. Consider own level of competency 4. Determine the probability of all possible consequences
1, 2, 4
Review the following list of nursing diagnoses and identify those stated incorrectly. (Select all that apply) [17] 1. Acute pain related to lumbar disk repair 2. Sleep deprivation related to difficulty falling asleep 3. Constipation related to inadequate intake of fluids 4. Potential nausea related to nasogastric tube insertion
1, 2, 4
What technique(s) best encourage(s) a patient to tell his or her full story? (Select all that apply) [16] 1. Active listening 2. Back channeling 3. Validating 4. Use of open-ended questions 5. Use of closed-ended questions
1, 2, 4
A nurse identifies several interventions to resolve a patient's nursing diagnosis of "impaired skin integrity." Which of the following are written in error? (Select all that apply) [18] 1. Turn the patient regularly from side to back to side. 2. Provide perineal care, using Dove soap and water, every shift and after each episode of urinary incontinence 3. Apply a pressure-relief device to bed 4. Apply transparent dressing to sacral pressure ulcer
1, 3
A nurse working on a medicine nursing unit is assigned to a 78-year-old patient who just entered the hosprial with symptoms of H1N1 flu. The nurse finds the patient to be short of breath with an increased respiratory rate of 30 breaths/min. He lost his wife just a month ago. The nurse's knowledge about this patient results in which of the following assessment approaches at this time? (Select all that apply) [16] 1. A problem-focused approach 2. A structured comprehensive approach 3. Using multiple visits to gather a complete database 4. Focusing on the functional health pattern of the role-relationship
1, 3
A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as "deficient knowledge regarding insulin administration related to inexperience with disease management." What does the nurse need to determine before setting the goal of "patient will self-administer insulin?" (Select all that apply) [18] 1. Goal within reach of the patient 2. The nurse's own competency in teaching about insulin 3. The patient's cognitive function 4. Availability of family members to assist
1, 3, 4
To ensure the safe use of oxygen in the home by a patient, which of the following teaching points does the nurse include? (Select all that apply) [27] 1. Smoking is prohibited around oxygen 2. Demonstrate how to adjust the oxygen flow rate based on patient symptoms 3. Do not use electrical equipment around oxygen 4. Special precautions may be required when traveling with oxygen
1, 3, 4
Which of the following statements correctly describe the evaluation process? (Select all that apply) [20] 1. Evaluation is an ongoing process 2. Evaluation usually reveals obvious changes in patients 3. Evaluation involves making clinical decisions 4. Evaluation requires the use of assessment skills
1, 3, 4
Which steps does the nurse follow when he or she is asked to perform an unfamiliar procedure? (Select all that apply) [19] 1. Seeks necessary knowledge 2. Reassesses the patient's condition 3. Collects all necessary equipment 4. Delegates the procedure to a more experienced nurse 5. Considers all possible consequences of the procedure
1, 3, 5
Which of the following actions, if performed by a registered nurse, would result in both criminal and administrative law sanctions against the nurse? (Select all that apply.) [23] 1. Taking and selling controlled substances 2. Refusing to provide health care information to a patient's child 3. Reporting suspected abuse and neglect of children 4. Applying physical restraints without a written physician's order.
1, 4
Which of the following are examples of data validation? (Select all that apply) [16] 1. The nurse assesses the patient's heart rate and compares the value with the last value entered in the medical record 2. The nurse asks the patient if he is having pain and then asks the patient to rate the severity 3. The nurse observes a patient reading a teaching booklet and asks the patient if he has questions about its content 4. The nurse obtains a blood pressure value that is abnormal and asks the charge nurse to repeat the measurement 5. The nurse asks the patient to describe a symptom by saying "Go on."
1, 4
A nurse gathers the following assessment data. Which of the following cues form(s) a pattern suggesting a problem? (Select all that apply) [16] 1. The skin around the wound is tender to touch 2. Fluid intake for 8 hours is 800 mL 3. Patient has a heart rate of 78 and regular 4. Patient has drainage from surgical wound 5. Body temperature is 101F (38.3 C) 6. Patient asks, "I'm worried that I won't return to work when I planned."
1, 4, 5
The patient has a fractured femur that is placed in skeletal traction with a fresh plaster cast applied. The patient experiences decreased sensation and a cold feeling in the toes of the affected leg. The nurse observes that the patient's toes have become pale and cold but forgets to document this because one of the nurse's other patient's experienced cardiac arrest at the same time. Two days later the patient in skeletal traction has an elevated temperature, and he is prepared for surgery to amputate the leg below the knee. Which of the following statements regarding a breach of duty apply to this situation? (Select all that apply). [23] 1. Failure to document a change in assessment data 2. Failure to provide discharge instructions 3. Failure to follow the six rights of medication administration 4. Failure to use proper medical equipment ordered for patient monitoring 5. Failure to notify a health care provider about a change in the patient's condition
1, 5
What is a nurse's responsibility when administering prescribed opioid analgesics? Select all that apply. 1 Count the client's respirations. 2 Document the intensity of the client's pain. 3 Withhold the medication if the client reports pruritus. 4 Verify the number of doses in the locked cabinet before administering the prescribed dose.
1,2,4 Opioid analgesics can cause respiratory depression; the nurse must monitor respirations. The intensity of pain must be documented before and after administering an analgesic to evaluate its effectiveness. Because of the potential for abuse, the nurse is legally required to verify an accurate count of doses before taking a dose from the locked source and at the change of the shift. Pruritus is a common side effect that can be managed with antihistamines. It is not an allergic response, so it does not preclude administration. The nurse should not discard an opioid in a client's room. Any waste of an opioid must be witnessed by another nurse.
The client asks the nurse to recommend foods that might be included in a diet for diverticular disease. Which foods would be appropriate to include in the teaching plan? Select all that apply. 1 Whole grains 2 Cooked fruit and vegetables 3 Nuts and seeds 4 Lean red meats 5 Milk and eggs
1,2,5 With diverticular disease the patient should avoid foods that may obstruct the diverticuli. Therefore the fiber should be digestible, such as whole grains, and cooked fruits and vegetables. Milk and eggs have no fiber content but are good sources of protein. In clients with diverticular disease, nuts and seeds are contraindicated as they may be retained and cause inflammation and infection, which is known as diverticulitis. The client should also decrease intake of fats and red meats.
A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? Select all that apply. 1 Pain history, including location, intensity, and quality of pain 2 Client's purposeful body movement in arranging the papers on the bedside table 3 Pain pattern, including precipitating and alleviating factors 4 Vital signs such as increased blood pressure and heart rate 5 The client's family statement about increases in pain with ambulation
1,3 Accurate pain assessment includes pain history with the client's identification of pain location, intensity, and quality and helps the nurse to identify what pain means to the client. The pattern of pain includes time of onset, duration, and recurrence of pain and its assessment helps the nurse anticipate and meet the needs of the client. Assessment of the precipitating factors helps the nurse prevent the pain and determine it cause. Purposeless movements such as tossing and turning or involuntary movements such as a reflexive jerking may indicate pain. Physiological responses such as elevated blood pressure and heart rate are most likely to be absent in the client with chronic pain. Pain is a subjective experience and therefore the nurse has to ask the client directly instead of accepting statement of the family members.
A nurse is taking care of a client who has severe back pain as a result of a work injury. What nursing considerations should be made when determining the client's plan of care? Select all that apply. 1 Ask the client what is the client's acceptable level of pain. 2 Eliminate all activities that precipitate the pain. 3 Administer the pain medications regularly around the clock. 4 Use a different pain scale each time to promote patient education. 5 Assess the client's pain every 15 minutes
1,3 The nurse works together with the client in order to determine the tolerable level of pain. Considering that the client has chronic, not acute pain, the goal of the pain management is to decrease pain to the tolerable level instead of eliminating pain completely. Administration of pain medications around the clock will provide the stable level of pain medication in the blood and relieve the pain. Elimination of all activities that precipitate the client's pain is not possible even though the nurse will try to minimize such activities. The same pain scale should be used for assessment of the client's pain level helps to ensure consistency and accuracy in the pain assessment. Only management of acute pain such as postoperative pain requires the pain assessment at frequent intervals.
A nurse is teaching an adolescent about type 1 diabetes and self-care. Which questions from the client indicate a need for additional teaching in the cognitive domain? Select all that apply. 1 "What is diabetes?" 2 "What will my friends think?" 3 "How do I give myself an injection?" 4 "Can you tell me how the glucose monitor works?" 5 "How do I get the insulin from the vial into the syringe?
1,4 Acquiring knowledge or understanding aids in developing concepts, rather than skills or attitudes, and is a basic learning task in the cognitive domain. Values and self-realization are in the affective domain. Skills acquisition is in the psychomotor domain.
An older client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which interventions have specific gerontologic implications the nurse must consider? Select all that apply. 1 Assessment of skin turgor 2 Documentation of vital signs 3 Assessment of intake and output 4 Administration of antiemetic drugs 5 Replacement of fluid and electrolytes
1,4,5 When skin turgor is assessed, the presence of tenting may be related to loss of subcutaneous tissue associated with aging rather than to dehydration; skin over the sternum should be used instead of skin on the arm for checking turgor. Older adults are susceptible to central nervous system side effects, such as confusion, associated with antiemetic drugs; dosages must be reduced, and responses must be evaluated closely. Because many older adults have delicate fluid balance and may have cardiac and renal disease, replacement of fluid and electrolytes may result in adverse consequences, such as hypervolemia, pulmonary edema, and electrolyte imbalance. Vital signs can be obtained as with any other adult. Intake and output can be measured accurately in older adults.
What is the principle-based approach to bioethics?
1. Autonomy 2. Nonmaleficence 3. Beneficence 4. Justice 5. Fidelity 6. Veracity, accountability, privacy, and confidentiality
What are the six essential features of professional nursing? (Generally speaking).
1. Caring relationships that facilitate health and healing. 2. Being aware of the range of human responses to health and illness in their various environments. 3. Integrating objective date with the patient's or groups subjective experience. 4.Applying scientific knowledge to care for the patient, through the use of critical thinking. 5. Learning through scholarly inquiry. 6. Influence on the promotion of social justice.
Healthy people 2020's primary "guidelines" are:
1. Prevent disease, disability, and premature death. 2. Having high health equity, *eliminating disparities,* and improving the health of ALL groups. 3. Create a society that promotes good health for all. 4. Promotes continued high quality of life across all lifespans.
A health care provider prescribes 500 mg of an antibiotic intravenous piggyback (IVPB) every 12 hours. The vial of antibiotic contains 1 g and indicates that the addition of 2.5 mL of sterile water will yield 3 mL of reconstituted solution. How many milliliters of the antibiotic should be added to the 50 mL IVPB bag? Record your answer using one decimal place. __ mL
1.5
The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the nurse administer?
1.5ml
The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive?
124 gtt/min.
Seconal 0.1 gram PRN at bedtime is prescribed to a client for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer? A. 0.5 tablet. B. 1 tablet. C. 1.5 tablets. D. 2 tablets.
15 gr=1 Gm. Converting the prescribed dose of 0.1 grams to grains requires multiplying 0.1 × 15 = 1.5 grains. The tablets come in 1.5 grains, so the nurse should plan to administer 1 tablet (B). Correct Answer: B
A nurse is performing an admission assessment on a client. The nurse determines the client's radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client's pulse deficit?
16/min The pulse deficit is the difference between the apical and radial pulse rates. It reflects the number of ineffective or nonperfusing heartbeats that do not transmit pulsations to peripheral pulse points. 84-68 = 16
intimacy vs isolation
18 to 40
health BMI weight
18.5 to 25
A nurse from home health is talking with a nurse who works on an acute medical division within a hospital. The home health nurse is making a consultation. Which of the following statements describes the unique difference between a nursing care plan from a hospital verses one for home care? [18] 1. The goals of care will always be more long term 2. The patient and family need to be able to independently provide most of the health care 3. The patient's goals need to be mutually set with family members who will care for him or her 4. The expected outcomes need to address what can be influenced by interventions
2
A nurse is planning care for a patient going to surgery. Who is responsible for informing the patient about the surgery along with the possible risks, complications, and benefits? [23] 1. Family member 2. Surgeon 3. Nurse 4. Nurse Manager
2
A nursing student takes a patient's antibiotic to his room. The patient asks the nursing student what it is and why he should take it. Which information does the nursing student include when replying to the patient? [31] 1. Only the patient's physician can give this information 2. The student provides the name of the medication and a description of its desired effect 3. Information about medications is confidential and cannot be shared 4. He has to speak with his assigned nurse about this
2
A patient is being discharged after abdominal surgery. The abdominal incision is healing well with no signs or redness or irritation. Following instruction, the patient has demonstrated effective care of the incision, including cleansing the would and applying dressings correctly to the nurse. These behaviors are an example of: [20] 1. Evaluative measure 2. Expected outcome 3. Reassessment 4. Standard of care
2
A patient is recovering from surgery for removal of an ovarian tumor. It is 1 day after surgery. Because she has an abdominal incision and dressing and a history of diabetes, the nurse has selected a nursing diagnosis of "risk for infection." Which of the following is an appropriate goal statement for the diagnosis? [20] 1. Patient will remain afebrile to discharge 2. Patient's wound will remain free of infection by discharge 3. Patient will receive ordered antibiotic on time over next 3 days 4. Patient's abdominal incision will be covered with a sterile dressing for 2 days
2
After seeing a patient, the physician gives a nursing student a verbal order for a new medication. The nursing student first needs to: [31] 1. Follow ISMP guidelines for safe medication abbreviations 2. Explain to the physician that the order needs to be given to a registered nurse 3. Write the order on the patient's order sheet and read it back to the physician 4. Ensure that the six rights of medication administration are followed when giving the medication
2
If a patient who is receiving IV fluids develops tenderness, warmth, erythema, and pain at the site, the nurse suspects: [31] 1. Sepsis 2. Phlebitis 3. Infiltration 4. Fluid overload
2
If an infectious disease can be transmitted directly from one person to another, it is a: [28] 1. Susceptible host 2. Communicable disease 3. Port of entry to a host 4. Port of exit from the reservior
2
The nurse is having difficulty reading a physician's order for a medication. He or she knows that the physician is very busy and does not like to be called. What is the most appropriate next step for the nurse to take? [31] 1. Call the pharmacist to interpret the order 2. Call the physician to have the order clarified 3. Consult the unit manager to help interpret the order 4. Ask the unit secretary to interpret the physician's handwriting
2
The nurse reviews a patient's medical record and sees that tube feedings are to begin after a feeding tube is inserted. In recent past experiences the nurse has seen patients on the unit develop diarrhea from tube feedings. The nurse consults with the dietician and physician to determine the initial rate that will be ordered for the feeding to lessen the chance of diarrhea. This is an example of what type of direct care measure? [19] 1. Preventative 2. Controlling for adverse reaction 3. Consulting 4. Counseling
2
What is the best method to sterilize a straight urinary catheter and suction tube in the home setting? [28] 1. Use an autoclave 2. Use boiling water 3. Use ethylene oxide gas 4. Use chemicals for disinfection
2
While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the nurse take? 1 Immediately stop the infusion. 2 Lower the height of the enema bag. 3 Advance the enema tubing 2 to 3 inches. 4 Clamp the tube for 2 minutes, then restart the infusion.
2 Abdominal cramping during a soapsuds enema may be due to too rapid administration of the enema solution. Lowering the height of the enema bag slows the flow and allows the bowel time to adapt to the distention without causing excessive discomfort. Stopping the infusion is not necessary. Advancing the enema tubing is not appropriate. Clamping the tube for several minutes then restarting the infusion may be attempted if slowing the infusion does not relieve the cramps.
A client is receiving an intravenous (IV) infusion of 5% dextrose in water. The client loses weight and develops a negative nitrogen balance. The nurse concludes that what likely contributed to this client's weight loss? 1 Excessive carbohydrate intake 2 Lack of protein supplementation 3 Insufficient intake of water-soluble vitamins 4 Increased concentration of electrolytes in cells
2 An infusion of dextrose in water does not provide proteins required for tissue growth, repair, and maintenance; therefore, tissue breakdown occurs to supply the essential amino acids. Each liter provides approximately 170 calories, which is insufficient to meet minimal energy requirements; tissue breakdown will result. Weight loss is caused by insufficient nutrient intake; vitamins do not prevent weight loss. An infusion of 5% dextrose in water may decrease electrolyte concentration.
A toddler screams and cries noisily after parental visits, disturbing all the other children. When the crying is particularly loud and prolonged, the nurse puts the crib in a separate room and closes the door. The toddler is left there until the crying ceases, a matter of 30 or 45 minutes. Legally, how should this behavior be interpreted? 1 Limits had to be set to control the child's crying. 2 The child had a right to remain in the room with the other children. 3 The child had to be removed because the other children needed to be considered. 4 Segregation of the child for more than half an hour was too long a period of time
2 Legally, a person cannot be locked in a room (isolated) unless there is a threat of danger either to the self or to others. Limit setting in this situation is not warranted. This is a reaction to separation from the parent, which is common at this age. Crying, although irritating, will not harm the other children. A child should never be isolated
A nurse is caring for a client with an impaired immune system. Which blood protein associated with the immune system is important for the nurse to consider? 1 Albumin 2 Globulin 3 Thrombin 4 Hemoglobin
2 The gamma-globulin fraction in the plasma is the fraction that includes the antibodies. Albumin helps regulate fluid shifts by maintaining plasma oncotic pressure. Thrombin is involved with clotting. Hemoglobin carries oxygen.
A nurse is preparing to administer an oil-retention enema and understands that it works primarily by: 1 Stimulating the urge to defecate. 2 Lubricating the sigmoid colon and rectum. 3 Dissolving the feces. 4 Softening the feces
2 The primary purpose of an oil-retention enema is to lubricate the sigmoid colon and rectum. Secondary benefits of an oil-retention enema include stimulating the urge to defecate and softening feces. An oil-retention enema does not dissolve feces.
In what position should the nurse place a client recovering from general anesthesia? 1 Supine Correct2 Side-lying 3 High Fowler 4 Trendelenburg
2 Turning the client to the side promotes drainage of secretions and prevents aspiration, especially when the gag reflex is not intact. This position also brings the tongue forward, preventing it from occluding the airway when it is in the relaxed state. The risk for aspiration is increased when the supine position is assumed by a semi-alert client. High Fowler position may cause the neck to flex in a client who is not alert, interfering with respirations. Trendelenburg position is not used for a postoperative client because it interferes with breathing.
A nurse is preparing to administer metoprolol 200 mg PO daily. The amount available is metoprolol 100 mg/tablet. How may tablets should the nurse administer? (Round the answer to the nearest whole number. Do not use a trailing zero).
2 tablets
Which of the following are "never" events—events that can cause serious injury or death to a patient and should never happen in a hospital? SELECT ALL THAT APPLY. 1) Myocardial infarction resulting from atherosclerosis 2) A surgical sponge left in a patient after surgery 3) Anaphylactic response to latex gloves 4) The wrong type of blood given to a patient 5) Severe pressure ulcers 6) Injuries from restraints
2) A surgical sponge left in a patient after surgery 4) The wrong type of blood given to a patient 5) Severe pressure ulcers 6) Injuries from restraints
A child has just been brought into the emergency room for suspected poisoning. Which of the following interventions should you most expect to be ordered? 1) Administering ipecac syrup to induce vomiting 2) Administering activated charcoal 3) Mechanically inducing vomiting by triggering the child's gag reflex 4) Performing the Heimlich maneuver
2) Administering activated charcoal
You are caring for an ambulatory male client and would like to promote normal urination in him. Which of the following actions should you take? SELECT ALL THAT APPLY. 1) Stand outside the bathroom door while he is urinating and ask, "Are you okay?" occasionally to reassure him of your presence in case he needs you. 2) Allow the client to stand and use the toilet in the bathroom for urination, if he is able, instead of using the urinal in bed. 3) Prompt the patient to urinate at different times each day for the sake of variety. 4) Encourage the client to drink eight to ten 8-ounce glasses of fluid daily. 5) Excuse visitors from the room when discussing care related to urination. 6) Explain to the client that the diuretic he will be taking will cause him to urinate more often.
2) Allow the client to stand and use the toilet in the bathroom for urination, if he is able, instead of using the urinal in bed. 4) Encourage the client to drink eight to ten 8-ounce glasses of fluid daily. 5) Excuse visitors from the room when discussing care related to urination. 6) Explain to the client that the diuretic he will be taking will cause him to urinate more often.
A nurse if preparing to assess a toddler. To make it go smoothly the nurse should _____________? 1) Ask the parents to step out 2) Ask the child about his favorite toy 3) Show the child your name tag 4) Yell at the child if he doesn't follow instructions
2) Ask the child about his favorite toy This will show the child that you are interested in his things.
The nurse is developing a teaching plan for an older adult patient with Alzheimer disease and her family. Which point should the nurse include in the teaching plan before discharge? 1) Importance of quitting smoking. 2) Availability of community resources. 3) Adherence to a low-fat diet 4) Importance of physical exercise.
2) Availability of community resources.
You are caring for a client who has undergone a total colectomy with ileoanal reservoir. With this type of bowel diversion, how will the client accomplish bowel elimination? 1) By inserting a tube through an external stoma into an internal pouch to drain it several times per day 2) By evacuating the bowel on a commode in the usual way; however, the feces will still be liquid 3) By emptying an external ostomy bag attached to a stoma 4) By receiving total parenteral nutrition, completely bypassing the gastrointestinal system
2) By evacuating the bowel on a commode in the usual way; however, the feces will still be liquid
You are caring for a client who is a sprinter on her high school track team. You should especially encourage her to consume which of the following nutrients to provide plenty of energy before running? 1) Protein 2) Carbohydrate 3) Lipid 4) Water
2) Carbohydrate
A client is returning to your clinic 3 days after having received an intradermal injection of antigen as part of a tuberculin skin test. As you palpate the injection site, you find that it has become hard. Which of the following should you anticipate as the next intervention ordered by the primary care provider? 1) No further intervention, as the test is negative for tuberculosis 2) Chest x-ray and sputum culture 3) Pulse oximetry 4) Spirometry
2) Chest x-ray and sputum culture
Patients may be deficient in which vitamin during the winter months? 1) A 2) D 3) K 4) E
2) D
When changing a diaper, the nurse observes that a 2 day old infant has a green, black, tarry stool. What should the nurse do? 1) notify the physician 2) Do nothing, this is normal 3) Give the baby sterile water 4) Apply a skin barrier
2) Do nothing this is normal
A female client complains of a stinging sensation when she urinates. You suspect a urinary tract infection (UTI). Which of the following are additional signs and symptoms of UTI that you should assess for in this client? SELECT ALL THAT APPLY. 1) Decreased urge to urinate 2) Foul-smelling urine 3) Blood in the urine 4) Back pain 5) Headache 6) Abdominal cramps
2) Foul-smelling urine 3) Blood in the urine 4) Back pain
Which question helps the nurse assess family structure? 1) Where does your family live? 2) How are family decisions made? 3) With which religious affiliation is your family associate? 4) What is your ethnic background?
2) How are family decisions made? Asking how family decisions are made helps the nurse assess family structure.
You receive laboratory test results for a client and note that her creatinine level is increased above normal. This finding most likely points to which of the following? 1) Diabetes mellitus 2) Impaired kidney function 3) Malnutrition 4) Inadequate iron intake
2) Impaired kidney function
You are teaching a client about the benefits of regular aerobic exercise. Which of the following should you mention? SELECT ALL THAT APPLY. 1) Decreases risk of musculoskeletal injury 2) Improves the pumping action of the heart 3) Decreases heart rate 4) Decreases risk of dehydration 5) Dilates bronchioles to increase ventilation 6) Improves bone mass with aging
2) Improves the pumping action of the heart 3) Decreases heart rate 5) Dilates bronchioles to increase ventilation 6) Improves bone mass with aging
You are caring for a client who is receiving morphine for pain relief. After the latest dose, you notice that the client's respiratory rate has declined to 10 breaths per minute. Which of the following nursing diagnoses would be most appropriate for this client? 1) Ineffective Airway Clearance (respiratory depression) related to overdose of morphine 2) Ineffective Breathing Pattern (hypoventilation) related to overdose of morphine 3) Impaired Gas Exchange related to respiratory depression secondary to overdose of morphine 4) Impaired Spontaneous Ventilation related to hypoventilation secondary to overdose of morphine
2) Ineffective Breathing Pattern (hypoventilation) related to overdose of morphine
You are providing nutritional counseling to a vegan client. You encourage the client to include sources rich in vitamin C in her diet. Which of the following is the best rationale for this advice? 1) Vegans tend not to eat foods that contain vitamin C. 2) It is easier to absorb iron from plant sources when it is eaten with foods containing vitamin C. 3) Foods rich in vitamin C are also typically excellent sources of protein. 4) Vitamin C is an excellent substitute for animal protein.
2) It is easier to absorb iron from plant sources when it is eaten with foods containing vitamin C.
You are performing a physical examination of a client when she begins to become agitated. When you ask what is wrong, she says, "I think I'm having a panic attack." Her respirations increase in rate and depth but remain regular. Which breathing pattern is this? 1) Bradypnea 2) Kussmaul's respirations 3) Biot's respirations 4) Cheyne-Stokes respirations
2) Kussmaul's respirations
You are caring for a client who frequently experiences urinary stress incontinence. She has a body mass index (BMI) of 32. Which of the following lifestyle modifications should you encourage the client to make? SELECT ALL THAT APPLY. 1) Decrease fluid intake to three or four 8 ounce glasses per day. 2) Limit caffeine intake to less than 100 mg daily.3) Lose weight. 4) Engage in high-impact exercise. 5) Take prescribed diuretics at night. 6) Avoid constipation.
2) Limit caffeine intake to less than 100 mg daily. 3) Lose weight. 6) Avoid constipation.
______________ is a health program, administered by the state and funded by federal and state governments to provide care for low-income people. 1) Medicare 2) Medicaid 3) Obama care 4) Welfare
2) Medicaid Medicaid is intended to provide healthcare individuals without ability to pay for services. Medicare is designed to protect people age 65 and older from the rising cost of healthcare.
You are preparing to perform routine nutritional screening on an older client who was just admitted to the hospital. Which of the following tools would be best for this purpose? 1) Cursory screening 2) Mini Nutritional Assessment 3) Food frequency questionnaire 4) Food record
2) Mini Nutritional Assessment
You are caring for a client with emphysema who frequently experiences shortness of breath. Which of the following positions would be best to place the client in? 1) Semi-Fowler's 2) Orthopneic 3) Lateral 4) Sims'
2) Orthopneic
You are helping an obese client develop an exercise plan. Which of the following is a likely barrier to exercise that is associated with obesity? 1) Muscle wasting 2) Osteoarthritis 3) Negative nitrogen balance 4) Inadequate protein stores available to maintain or repair body tissue
2) Osteoarthritis
Which of the following includes objective and subjective data? 1) Patient's BP is 132/68 and HR is 88 2) Patient's cholesterol is elevated, and stated that he likes fried food 3) Patient states she is having trouble sleeping and drinks coffee at night 4) Patient states he gets frequent headaches and takes aspirin for it.
2) Patient's cholesterol is elevated, and stated that he likes fried food Elevated cholesterol is objective and states "likes fried food" is subjective
After suffering a heart attack, a patient needs cardiac rehabilitation. This will help to gradually build his exercise tolerance. According to Maslow's Hierarchy of needs, cardiac rehab addresses what need? 1) Safety and Security 2) Physiological 3) Self-actualization 4) Self-esteem
2) Physiological Cardiac rehabilitation most directly addresses the patient's physiological need for physical activity as well as health and healing.
You are providing care to a client with pneumonia. Which of the following interventions would be most appropriate for helping this client mobilize and expel secretions? 1) Use a dehumidifier in the client's room. 2) Position the client for postural drainage and perform chest percussion. 3) Administer oxygen at 95% via a Venturi mask. 4) Discourage the client from taking fluids by mouth.
2) Position the client for postural drainage and perform chest percussion.
A patient and his wife are 2 years from retirement when he is diagnosed with lung cancer. Although with delayed child-bearing, developmental stages can vary among families, which typical stage of family development is this couple most likely experiencing? 1) Family launching young adults 2) Postparental family 3) Family with frail elderly 4) Family with teenagers and young adults.
2) Postparental family
You are caring for a client who has recently been diagnosed with diabetes. On questioning the client, you learn that she is sexually active and that in the past she has experienced a stinging sensation while urinating, although she currently is not experiencing any such symptoms. Which of the following nursing diagnoses would be most appropriate for this client? 1) Readiness for Enhanced Urinary Elimination 2) Risk for Infection (Urinary Tract) 3) Risk for Urge Urinary Incontinence 4) Functional Urinary Incontinence
2) Risk for Infection (Urinary Tract)
You are discussing the benefits of smoking cessation with a client who has been smoking for 30 years. He says, "After all these years, will it even make a difference?" Which of the following facts about smoking cessation should you communicate to this client? SELECT ALL THAT APPLY. 1) Risk of lung cancer remains the same. 2) Risk of heart attack returns to that of a nonsmoker in 1 year. 3) Life expectancy increases. 4) Oxygen levels in the blood begin to improve within 8 days. 5) Blood pressure and heart rate decrease. 6) Coughing, congestion, and shortness of breath decrease.
2) Risk of heart attack returns to that of a nonsmoker in 1 year. 3) Life expectancy increases. 5) Blood pressure and heart rate decrease. 6) Coughing, congestion, and shortness of breath decrease.
Nursing research is based on the _________________ method. 1) Qualitative 2) Scientific 3) Self-transcendence 4) Mechanical
2) Scientific
A client recently sustained a back injury from improper lifting while at work. You are instructing him on how to achieve proper balance when lifting to avoid injury in the future. Which of the following instructions should you give him? SELECT ALL THAT APPLY. 1) Place your center of gravity farthest from your base of support. 2) Stand with your head erect. 3) Pull in your buttocks. 4) Keep your abdominal muscles tight. 5) Roll your shoulders forward. 6) Keep your feet together.
2) Stand with your head erect. 3) Pull in your buttocks. 4) Keep your abdominal muscles tight.
A client with heart disease is describing his bowel function to you during a nursing history interview. Which of the following should you be concerned about? SELECT ALL THAT APPLY. 1) Bowel movements occur every other day. 2) The client has to rush to the toilet often to defecate. 3) The client often has to use the Valsalva maneuver when defecating. 4) There is bright red blood mixed with the stool. 5) The stool is soft and semisolid. 6) The client frequently uses laxatives.
2) The client has to rush to the toilet often to defecate. 3) The client often has to use the Valsalva maneuver when defecating. 4) There is bright red blood mixed with the stool. 6) The client frequently uses laxatives.
When providing postmortem care, why would the nurse place dentures in the mouth and close the eyes and mouth of the patient within 2 to 4 hours after death? 1) To prevent blood from settling in the head, neck, and shoulders 2) To preform these actions more easily before rigor mortis develops 3) To set mouth in natural position fro viewing by the family 4) To prevent discoloration caused by blood settling in the facial area.
2) To preform these actions more easily before rigor mortis develops
You are measuring the intake and output of a client. Which of the following should you include in the patient's output? SELECT ALL THAT APPLY. 1) Irrigations 2) Urine3) Emesis 4) Intravenous (IV) fluids 5) Liquid feces 6) Drainage from a wound
2) Urine 3) Emesis 5) Liquid feces 6) Drainage from a wound
The nurse is preparing a patient for a CT scan of the abdomen, which statement by the nurse is the best? 1) You will need to remain NPO for 4 hours prior to CT scan 2) You cannot have anything to eat or drink before your test 3) You will need to be NPO and drink this contrast 4) You may need to void before your CT scan
2) You cannot have anything to eat or drink before your test
Which form of communication is the nurse using when interviewing the patient during the admission health history and physical assessment? 1) small group 2) interpersonal 3) group 4) intrapersonal
2) interpersonal
A clinic nurse assesses a patient who reports a loss of appetite and a 15-pound weight loss since 2 months ago. The patient is 5 feet 10 inches tall and weighs 135 pounds (61.2 kg). She shows signs of depression and does not have a good understanding of foods to eat for proper nutrition. The nurse makes the nursing diagnosis of "imbalanced nutrition: less than body requirements related to reduced intake of food." For the goal of "Patient will return to baseline weight in 3 months," which of the following outcomes would be appropriate? (Select all that apply) [20] 1. Patient will discuss source of depression by next clinic visit. 2. Patient will acheive a calorie intake of 2400 daily in 2 weeks. 3. Patient will report improvement in appetite in 1 week. 4. Patient will identify food protein sources
2, 3
A nurse assesses a 78-year-old patient who weighs 240 pounds (108.9 kg) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of "risk for impaired skin integrity." Which of the following goals are appropriate for the patient? (Select all that apply) [18] 1. Patient will be turned every 2 hours within 24 hours 2. Patient will have normal bowel function within 72 hours 3. Patient's skin will remain intact through discharge 4. Patient's skin condition will improve by discharge
2, 3
A nurse is assigned to a patient who has returned from the recovery room following surgery for a colorectal tumor. After an initial assessment the nurse anticipates the need to monitor the patient's abdominal dressing, IV infusion, and function of drainage tubes. The patient is in pain, reporting 6 on a scale of 0-10, and will not be able to eat or drink until intestinal function returns. The family has been in the waiting room for an hour, wanting to see the patient. The nurse establishes priorities first for which of the following situations? (Select all that apply) [18] 1. The family comes to visit the patient 2. The patient expresses concern about pain control 3. The patient's vital signs change, showing a drop in blood pressure. 4. The charge nurse approaches the nurse and requests a report at end of shift.
2, 3
In which of the following examples is a nurse applying critical thinking attitudes when preparing to insert an IV catheter? (Select all that apply) [19] 1. Following the procedural guideline for IV insertion 2. Seeking necessary knowledge about the steps of the procedure from a more experienced nurse 3. Showing confidence in performing the correct IV insertion technique 4. Being sure that the IV dressing covers the IV site completely
2, 3
Which of the following are examples of collaborative problems? (Select all that apply) [17] 1. Nausea 2. Hemorrhage 3. Wound infection 4. Fear
2, 3
A nurse on a cancer unit is reviewing and revising the written plan of care for a patient who has the nursing diagnosis of nausea. Place the steps in their proper order: [19] 1. The nurse revises approaches in the plan for controlling environmental factors that worsen nausea 2. The nurse enters data in the assessment column showing new information about the patient's nausea 3. The nurse adds the current date to show that the diagnosis of nausea is still relevant 4. The nurse decides to use the patient's self-report of appetite and fluid intake as evaluation measures
2, 3, 1, 4
The nurse enters a patient's room and finds that the patient was incontinent of liquid stool. The patient has recurrent redness in the perineal area, and there is concern that he is developing a pressure ulcer. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. She calls the ostomy and wound care specialist and asks that he visit the patient to recommend skin care measures. Which of the following describe the nurse's actions? (Select all that apply) [19] 1. The application of the skin barrier is a dependent measure 2. The call to the ostomy and wound care specialist is an indirect care measure 3. The cleansing of the skin is a direct care measure 4. The application of the skin barrier is a direct care measure
2, 3, 4
A nurse is caring for a patient who recently had coronary bypass surgery. Which are legal sources of standards of care the nurse uses to deliver safe healthcare? (Select all that apply). [23] 1. Information provided by the head nurse 2. Policies and procedures of the employing hospital 3. State Nurse Practice Act 4. Regulations identified in the Joint Commission's manual. 5. The American Nurses Association standards of practice.
2, 3, 4, 5
A nurse caring for a patient with pneumonia sits the patient up in bed and suctions his airway. After suctioning, the patient describes some discomfort in his abdomen. The nurse auscultates the patient's lung sounds and gives him a glass of water. Which of the following would be appropriate evaluative criteria used by the nurse? (Select all that apply) [20] 1. Patient drinks contents of water glass 2. Patient's lungs are clear to auscultation in bases 3. Patient reports abdominal pain on a scale of 0 to 10 4. Patient's rate and depth of breathing are normal with head of bed elevated
2, 4
A patient comes to a medical clinic with the diagnosis of asthma. The nurse practitioner decides that the patient's obesity adds to the difficulty of breathing; the patient is 5 feet 7 inches tall and weighs 200 pounds (90.7 kg). Based on the nursing diagnosis of "imbalanced nutrition: more than body requirements," the practitioner plans to place the patient on a therapeutic diet. Which of the following are evaluative measures for determining if the patient achieves the goal of a desired weight loss? (Select all that apply) [20] 1. The patient eats 2000 calories a day 2. The patient is weighed during each clinic visit 3. The patient discusses factors that increase the risk of an asthma attack 4. The patient's food diary that tracks intake of daily meals is reviewed
2, 4
A client is being admitted for a total hip replacement. When is it necessary for the nurse to ensure that a medication reconciliation is completed? Select all that apply. 1 After reporting severe pain 2 On admission to the hospital 3 Upon entering the operating room 4 Before transfer to a rehabilitation facility 5 At time of scheduling for the surgical procedure
2, 4 Medication reconciliation involves the creation of a list of all medications the client is taking and comparing it to the health care provider's prescriptions on admission or when there is a transfer to a different setting or service, or discharge. A change in status does not require medication reconciliation. A medication reconciliation should be completed long before entering the operating room. Total hip replacement is elective surgery, and scheduling takes place before admission; medication reconciliation takes place when the client is admitted.
An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult the nurse recalls what expected sensory losses associated with aging? Select all that apply. 1 Difficulty in swallowing 2 Diminished sensation of pain 3 Heightened response to stimuli 4 Impaired hearing of high-frequency sounds 5 Increased ability to tolerate environmental heat
2,4 Because of aging of the nervous system an older adult has a diminished sensation of pain and may be unaware of a serious illness, thermal extremes, or excessive pressure. As people age they experience atrophy of the organ of Corti and cochlear neurons, loss of the sensory hair cells, and degeneration of the stria vascularis, which affects an older person's ability to perceive high-frequency sounds. An interference with swallowing is a motor, not a sensory, loss, nor is it an expected response to aging. There is a decreased, not heightened, response to stimuli in older adults. There is a decreased, not increased, ability to physiologically adjust to extremes in environmental temperature.
The nurse recognizes that which are important components of a neurovascular assessment? Select all that apply. 1 Orientation 2 Capillary refill 3 Pupillary response 4 Respiratory rate 5 Pulse and skin temperature 6 Movement and sensation
2,5,6, A neurovascular assessment involves evaluation of nerve and blood supply to an extremity involved in an injury. The area involved may include an orthopedic and/or soft tissue injury. A correct neurovascular assessment should include evaluation of capillary refill, pulses, warmth and paresthesias, and movement and sensation. Orientation, pupillary response, and respiratory rate are components of a neurological assessment.
Below are the step-by-step instructions for collecting a 24-hour urine specimen. Put them in the correct order. 1. Collect all urine voided during the next 24 hours. 2. Ask the patient to void. 3. Transport the specimen to the laboratory. 4. Label the storage container with the patient's name, the date, and the time the test ended. 5. Record the time. 6. Discard the voiding.
2. Ask the patient to void. 5. Record the time. 6. Discard the voiding. 1. Collect all urine voided during the next 24 hours. 4. Label the storage container with the patient's name, the date, and the time the test ended. 3. Transport the specimen to the laboratory.
The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute?
21
A home health nurse notices significant bruising on the 2-year-old patient's head, arms, abdomen, and legs. The patient's mother describes the patient's frequent falls. What is the best nursing action for the home health nurse to take? [23] 1. Document her findings and treat the patient 2. Instruct the mother on safe handling of a 2-year-old child 3. Contact a child abuse hotline 4. Discuss this story with a colleague
3
A nurse is administering medications to a 4-year-old patient. After he or she explains which medications are being given, the mother states, "I don't remember my child having that medication before." What is the nurse's next action? [31] 1. Give the medication 2. Identify the patient using two identifiers 3. Withhold the medications and verify the medication orders 4. Provide medication education to the mother to help her better understand her child's medications
3
A nurse is orienting a new graduate nurse to the unit. The graduate nurse asks, "Why do we have standing orders for cases when patients develop life-threatening arrhythmias? Is not each patient's situation unique?" What is the nurse's best answer? [19] 1. Standing orders are used to meet our physician's preferences. 2. Standing orders ensure that we are familiar with evidence-based guidelines for care of arrhythmias 3. Standing orders allow us to respond quickly and safely to a rapidly changing situation 4. Standing orders minimize the documentation we have to provide
3
A nurse is preparing for change-of-shift rounds with the nurse who is assuming care for his patients. Which of the following statements or actions by the nurse are characteristics of ineffective handoff communication? [18] 1. This patient is anxious about his pain after surgery; you need to review the information I gave him about how to use a patient-controlled analgesia (PCA) pump this evening 2. The nurse refers to the electronic care plan in the electronic health record (EHR) to review interventions for the patient's care 3. During walking rounds the nurse talks about the problem the patient care technicians created by not ambulating the patient 4. The nurse gives her patient a pain medication before report so there is likely to be no interruption during rounding
3
A nurse is talking with a patient who is visiting a neighborhood health clinic. The patient came to the clinic for repeated symptoms of a sinus infection. During their discussion the nurse check the patient's medical record and realizes that he is due for a tetanus shot. Administering the shot is an example of what type of preventative intervention? [19] 1. Tertiary 2. Direct care 3. Primary 4. Secondary
3
A nurse notes that the health care unit keeps a listing of the patient names at the front desk in easy view for health care providers to more efficiently locate the patient. The nurse talks with the nursing manager because this action is a violoation of which act? [23] 1. Mental Health Parity Act 2. Patient Self-Determination Act (PSDA) 3. Health Insurance Portability and Accountability Act (HIPPA) 4. Emergency Medical Treatment and Active Labor Act
3
A nurse stops to help in an emergency at at the scene of an accident. The injured party files a suit and the nurse's employing institution insurance does not cover the nurse. What would probably cover the nurse in this situation? [23] 1. The nurse's auto insurance 2. The nurse's homeowner's insurance 3. The Good Samaritan laws, which grant immunity from suit if there is no gross negligence. 4. The Patient Care Partnership, which may grant immunity from suit if the injured party contends.
3
A nursing student is talking with one of the staff nurses who works on a surgical unit. The student's care plan is to include nursing-sensitive outcomes for the nursing diagnosis of "acute pain." A nursing-sensitive outcome suitable for this diagnosis would be: [20] 1. Patient will achieve pain relief by discharge 2. Patient will be free of a surgical wound infection by discharge 3. Patient will report reduced pain severity in 2 days 4. Patient will describe purpose of pain medicine by discharge
3
A parent calls the pediatrician's office frantic about the bottle of cleaner that her 2-year-old son drank. Which of the following is the most important instruction the nurse gives to this parent? [27] 1. Give the child milk 2. Give the child syrup of ipecac 3. Call the poison control center 4. Take the child to the emergency department
3
A patient has an indwelling urinary catheter. Why does an indwelling urinary catheter present a risk for urinary tract infection? [28] 1. It keeps an incontinent patient's skin dry 2. It can get caught in the linens or equipment 3. It obstructs the normal flushing action of urine flow 4. It allows the patient to remain hydrated without having to urinate
3
A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as "deficient knowledge regarding insulin administration related to inexperience with disease management." Which of the following patient care goals are long term? [18] 1. Patient will explain relationship of insulin to blood glucose control 2. Patient will self-administer insulin 3. Patient will achieve glucose control 4. Patient will describe steps for preparing insulin in a syringe
3
A patient is isolated for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention? [28] 1. Provide a dark, quiet room to calm the patient 2. Reduce the level of precautions to keep the patient from angry 3. Explain the reasons for isolation procedures and provide meaningful stimulation 4. Limit family and other caregiver visits to reduce the risk of spreading infection
3
A patient is receiving an IV push medication. If the drug infiltrates into the outer tissues, the nurse: [31] 1. Continues to let the IV run 2. Applies a warm compress to the infiltrated site 3. Stops the administration of the medicine and follows agency policy 4. Should not worry about this because vesicant filtration is not a problem
3
A patient is transitioning from the hospital to the home environment. A home care referral is obtained. What is a priority in relation to safe medication administration for the discharge nurse? [31] 1. Set up the follow-up appointments with the physician for the patient 2. Ensure that someone will provide housekeeping for the patient at home 3. Ensure that the home care agency is aware of medication and health teaching needs. 4. Make sure that the patient's family knows how to safely bathe him or her and provide mouth care.
3
A patient tells the nurse during a visit to the clinic that he has been sick to his stomach for 3 days and he vomited twice yesterday. Which of the following responses by the nurse is an example of probing? [16] 1. So you've had an upset stomach and began vomiting - correct? 2. Have you taken anything for your stomach? 3. Is anything else bothering you? 4. Have you taken any medication for your vomiting?
3
A patient's surgical wound has become swollen, red, and tender. You note that the patient has a new fever and leukocytosis. What is the best immediate intervention? [28] 1. Notify the health care provider and use surgical technique to change the dressing 2. Reassure the patient and check the wound later 3. Notify the health care provider and support the patient's fluid and nutritional needs 4. Alert the patient and caregivers to the presence of an infection to ensure care after discharge
3
The nurse asks a patient, "Describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?" This series of questions would likely occur during which phase of a patient-centered interview? [16] 1. Setting the stage 2. Gather information about a patient's chief concerns 3. Collecting the assessment 4. Termination
3
The nurse enters a patient's room, and the patient asks if he can get out of bed and transfer to a chair. The nurse takes precautions to use safe patient handling techniques and transfers the patient. This is an example of which physical care technique? [19] 1. Meeting the patient's expressed wishes 2. Indirect care measure 3. Protecting a patient from injury 4. Staying organized when implementing a procedure
3
The nurse makes the following statement during a change of shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, but I don't think it's that severe. You know that back patients often have chronic pain. He seems fine when talking with his family. Have you cared for him before?" What does the nurse's conclusion suggest? [16] 1. The nurse is making an accurate clinical inference 2. The nurse has gathered cues to identify a potential problem area 3. The nurse has allowed stereotyping to influence her assessment 4. The nurse wants to validate her information with the other nurse
3
The nurse received a hand-off report at the change of shift in the conference room from the night shift nurse. The nursing student assigned to the nurse asks to review the medical records of the patients assigned to them. The nurse begins assessing the assigned patients and lists the nursing care information for each patient on each individual patient's message board in the patient rooms. The nurse also lists the patient's medical diagnoses on the message board. Later in the day, the nurse discusses the plan of care for a patient who is dying with the patient's family. Which of these actions describes a violation of the Health Insurance Portability and Accountability Act (HIPPA)? [23] 1. Discussing the patient conditions in the nursing report room at the change of shift 2. Allowing nursing students to review patient charts before caring for patients to whom they are assigned 3. Posting medical information about the patient on a message board in the patient's room 4. Releasing patient information regarding terminal illness to family when the patient has given permission for information to be shared
3
The nurse's first action after discovering an electrical fire in a patient's room is to: [27] 1. Activate the fire alarm 2. Confine the fire by closing all doors and windows 3. Remove all patients in immediate danger 4. Extinguish the fire by using the nearest fire extinguisher
3
The nursing diagnosis readiness for enhanced communication is an example of a(n): [17] 1. Risk nursing diagnosis 2. Actual nursing diagnosis 3. Health promotion nursing diagnosis 4. Wellness nursing diagnosis
3
Two nurses are having a discussion at the nurses' station. One nurse is a new graduate who added, "Patient needs improved bowel function related to constipation" to a patient's care plan. The nurse's colleague, the charge nurse says, "I think your diagnosis is possibly worded incorrectly. Let's go over it together." A correctly worded diagnostic statement is: [17] 1. Need for improved bowel function related to change in diet 2. Patient needs improved function related to alteration in elimination 3. Constipation related to inadequate fluid intake 4. Constipation related to hard infrequent stools
3
When does implementation begin as the fourth step of the nursing process? [19] 1. During the assessment phase 2. Immediately in some critical situations 3. After the care plan has been developed 4. After there is mutual goal setting between a nurse and patient
3
To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what does the nurse expect the dietary plan to include? 1 Low in fat 2 High in iron 3 High in fluids 4 Low in residue
3 A common side effect of vincristine is a paralytic ileus that results in constipation. Preventative measures include high-fiber foods and fluids that exceed minimum requirements. These will keep the stool bulky and soft, thereby promoting evacuation. Low in fat, high in iron, and low in residue dietary plans will not provide the roughage and fluids needed to minimize the constipation associated with vincristine.
A nurse is providing care to a client eight hours after the client had surgery to correct an upper urinary tract obstruction. Which assessment finding should the nurse report to the surgeon? 1 Incisional pain 2 Absent bowel sounds 3 Urine output of 20 mL/hour 4 Serosanguineous drainage on the dressing .
3 A urinary output of 50 mL/hr or greater is necessary to prevent stasis and consequent infections after this type of surgery. The nurse should notify the surgeon of the assessment findings, since this may indicate a urinary tract obstruction. Incisional pain, absent bowel sounds, and serosanguineous drainage are acceptable assessment findings for this client after this procedure and require continued monitoring but do not necessarily require reporting to the surgeon
The nurse is providing postoperative care to a client who had a submucosal resection (SMR) for a deviated septum. The nurse should monitor for what complication associated with this type of surgery? Incorrect1 Occipital headache 2 Periorbital crepitus 3 Expectoration of blood 4 Changes in vocalization
3 After an SMR, hemorrhage from the area should be suspected if the client is swallowing frequently or expelling blood with saliva. A headache in the back of the head is not a complication of a submucosal resection. Crepitus is caused by leakage of air into tissue spaces; it is not an expected complication of SMR. The nerves and structures involved with speech are not within the operative area. However, the sound of the voice is altered temporarily by the presence of nasal packing and edema.
The triage nurse in the emergency department receives four clients simultaneously. Which of the clients should the nurse determine can be treated last? 1 Multipara in active labor 2 Middle-aged woman with substernal chest pain 3 Older adult male with a partially amputated finger 4 Adolescent boy with an oxygen saturation of 91%
3 Although a client with a partially amputated finger needs control of bleeding, the injury is not life threatening and the client can wait for care. A woman in active labor should be assessed immediately because birth may be imminent. A woman with chest pain may be experiencing a life-threatening illness and should be assessed immediately. An adolescent with significant hypoxia may be experiencing a life-threatening illness and should be assessed immediately.
The nurse is caring for a client that is on a low carbohydrate diet. With this diet, there is decreased glucose available for energy, and fat is metabolized for energy resulting in an increased production of which substance in the urine? 1 Protein 2 Glucose 3 Ketones 4 Uric Acid
3 As a result of fat metabolism, ketone bodies are formed and the kidneys attempt to decrease the excess by filtration and excretion. Excessive ketones in the blood can cause metabolic acidosis. A low carbohydrate diet does not cause increased protein, glucose, or uric acid in the urine. Study Tip: The old standbys of enough sleep and adequate nutritional intake also help keep excessive stress at bay. Although nursing students learn about the body's energy needs in anatomy and physiology classes, somehow they tend to forget that glucose is necessary for brain cells to work. Skipping breakfast or lunch or surviving on junk food puts the brain at a disadvantage.
A nurse is caring for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) in the urine. The health care provider orders an indwelling urinary catheter to be inserted. Which precaution should the nurse take during this procedure? 1 Droplet precautions 2 Reverse isolation 3 Surgical asepsis 4 Medical asepsis
3 Catheter insertion requires the procedure to be performed under sterile technique . Droplet precautions are used with certain respiratory illnesses. Reverse isolation is used with clients who may be immunocompromised. Medical asepsis involves clean technique/gloving.
A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has vancomycin-resistant Entercoccus (VRE). After notifying the physician, which action should the nurse take to decrease the risk of transmission to others? 1 Insert a urinary catheter. 2 Initiate droplet precautions. 3 Move the client to a private room. 4 Use a high efficiency particulate air (HEPA) respirator during care.
3 Contact precautions are used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment; therefore infectious clients must be placed in a private room. There is no need to insert an indwelling catheter, as this can increase the risk for additional infection. Droplet precautions are used for clients known or suspected to have infections transmitted by the droplet route. These infections are caused by organisms in droplets that may travel 3 feet, but are not suspended for long periods.
The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer dementia. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen the client is to take medications six times throughout the day. What is the priority nursing intervention to assist the client with taking the medication? 1 Contact the client's children and ask them to hire a private duty aide who will provide round-the-clock care. 2 Develop a chart for the client, listing the times the medication should be taken. 3 Contact the primary health care provider and discuss the possibility of simplifying the medication regimen. 4 Instruct the client and client's children to put medications in a weekly pill organizer
3 Contacting a medical care provider and discussing the possibility of simplifying the client's medication regimen will make it possible to use a weekly pill organizer : an empty pill box will remind the client who has a short-term memory deficit due to Alzheimer dementia that medication was taken and will prevent medication being taken multiple times. The client does not require 24-hour supervision because the client is in the outset of the Alzheimer dementia and the major issue is a short-term memory loss. A chart may be complex and difficult to understand for the client and will require the client to perform cognitive tasks multiple times on daily basis that may be beyond the client's ability. Use of the weekly pill organizers will be difficult with the current medication regimen when the client has to take medications six times a day; the medication regimen has to be simplified first.
A client has an anaphylactic reaction after receiving intravenous penicillin. What does the nurse conclude is the cause of this reaction? 1 An acquired atopic sensitization occurred. 2 There was passive immunity to the penicillin allergen. 3 Antibodies to penicillin developed after a previous exposure. 4 Potent antibodies were produced when the infusion was instituted
3 Hypersensitivity results from the production of antibodies in response to exposure to certain foreign substances (allergens). Earlier exposure is necessary for the development of these antibodies. This is not a sensitivity reaction to penicillin; hay fever and asthma are atopic conditions. It is an active, not passive, immune response. Antibodies developed when there was a previous, not current, exposure to penicillin.
A client is to have mafenide (Sulfamylon) cream applied to burned areas. For which serious side effect of mafenide therapy should the nurse monitor this client? 1 Curling ulcer 2 Renal shutdown 3 Metabolic acidosis 4 Hemolysis of red blood cells
3 Mafenide interferes with the kidneys' role in hydrogen ion excretion, resulting in metabolic acidosis. Curling ulcer, renal shutdown, and hemolysis of red blood cells are not adverse effects of the drugs.
The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia? 1 Crohn's 2 Cushing's 3 End-stage renal 4 Gastroesophageal reflux .
3 One of the kidneys' functions is to eliminate potassium from the body; diseases of the kidneys often interfere with this function, and hyperkalemia may develop, necessitating dialysis. Clients with Crohn's disease have diarrhea, resulting in potassium loss. Clients with Cushing's disease will retain sodium and excrete potassium. Clients with gastroesophageal reflux disease are prone to vomiting that may lead to sodium and chloride loss with minimal loss of potassium
When a client files a lawsuit against a nurse for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. This is known as: 1 Evidence 2 Tort discovery 3 Proximate cause 4 Common cause
3 Proximate cause is the legal concept meaning that the client must prove that the nurse's actions contributed to or caused the client's injury. Evidence is data presented in proof of the facts, which may include witness testimony, records, documents, or objects. A tort is a wrongful act, not including a breach of contract of trust that results in injury to another person. Common cause means to unite one's interest with another's.
A client asks about the purpose of a pulse oximeter. The nurse explains that it is used to measure the: 1 Respiratory rate. 2 Amount of oxygen in the blood. 3 Percentage of hemoglobin-carrying oxygen. 4 Amount of carbon dioxide in the blood
3 The pulse oximeter measures the oxygen saturation of blood by determining the percentage of hemoglobin-carrying oxygen. A pulse oximeter does not interpret the amount of oxygen or carbon dioxide carried in the blood, nor does it measure respiratory rate.
A client reaches the point of acceptance during the stages of dying. What response should the nurse expect the client to exhibit? 1 Apathy 2 Euphoria 3 Detachment 4 Emotionalism
3 When an individual reaches the point of being intellectually and psychologically able to accept death, anxiety is reduced and the individual becomes detached from the environment. Although detached, the client is not apathetic but still may be concerned and use time constructively. Although resigned to death, the individual is not euphoric. In the stage of acceptance, the client is no longer angry or depressed.
A nurse is preparing a community health program for senior citizens. The nurse teaches the group that the physical findings that are typical in older people include: 1 A loss of skin elasticity and a decrease in libido 2 Impaired fat digestion and increased salivary secretions 3 Increased blood pressure and decreased hormone production 4 An increase in body warmth and some swallowing difficulties
3 With aging, narrowing of the arteries causes some increase in the systolic and diastolic blood pressures; hormone production decreases after menopause. There may or may not be changes in libido; there is a loss of skin elasticity. Salivary secretions decrease, not increase, causing more difficulty with swallowing; there is some impairment of fat digestion. There may be a decrease in subcutaneous fat and decreasing body warmth; some swallowing difficulties occur because of decreased oral secretions.
You are obtaining a focused nursing history related to bowel elimination. Which of the following questions should you ask the client related to possible causes of constipation? 1) "How do you normally care for your stoma?" 2) "Is there any history of colorectal cancer in your family?" 3) "What medications are you currently taking?" 4) "To what are you allergic?"
3) "What medications are you currently taking?"
You are working with a female client who weighs 200 pounds. Using the formula provided in your text, which of the following is her basal metabolic rate in kilocalories (kcal) per day (24 hours)? 1) 1,835.8 2) 2,060.2 3) 1,963.4 4) 2,181.6
3) 1,963.4
Which of the following is an example of an illness prevention activity? 1) Encouraging the use of a food diary 2) Joining a cancer support group 3) Administering the immunization for HPV 4) Teaching a diabetic client about his diet
3) Administering the immunization for HPV This is a prevention activity.
A client who cannot manage a patient-controlled analgesia pump is prescribed morphine 4mg IV q 1 hr PRN for pain. When should the nurse administer the medication? 1) Every hour around the clock 2) Immediately after taking off the order 3) As needed, but not more than once per hour 4) 1 hour after the last dose administered.
3) As needed, but not more than once per hour
You are in a restaurant when you see a diner having difficulty breathing. Which of the following is the first thing you should do? 1) Perform the Heimlich maneuver. 2) Perform the choking rescue maneuver. 3) Ask the person, "Are you choking?" 4) Have someone call 911.
3) Ask the person, "Are you choking?"
A client has just been prescribed an iron supplement to treat anemia. You should warn the client that use of this medication will likely cause which of the following conditions? 1) Ulcers 2) Diarrhea 3) Constipation and black stool 4) Dependence on the medication and failure of the intestine to work properly
3) Constipation and black stool
Which of the following nursing interventions is an indirect-care intervention? 1) Emotional support 2) Teaching 3) Consulting 4) Physical care
3) Consulting
You are helping a client who has been confined to bed for over a week prepare for walking again. Which of the following measures should you specifically take to help prevent orthostatic hypotension in the client? 1) Quadriceps and gluteal drills 2) Pull-ups using a trapeze bar 3) Dangling the feet 4) Brushing the hair
3) Dangling the feet
You are providing nutritional counseling to a young woman who is trying to get pregnant. Which of the following vitamins should you especially encourage her to take? 1) Vitamin K 2) Vitamin B12 3) Folic acid 4) Vitamin D
3) Folic acid
A child is brought to the ER after swallowing liquid cleanser. He is awake, alert, and able to swallow. Which action should the nurse take first? 1) Administer a does of ipacac. 2) Administer activated charcoal 3) Give water to the child immediately 4) Call the nearest poison control center
3) Give water to the child immediately If the child is awake and able to swallow, and child has swallowed a household chemical, give a glass of water immediately and then call the poison control center.
You are assessing a 1-month-old breastfed baby. You ask the child's mother about his bowel movements and she describes them to you. Given the child's diet and stage of development, which of the following types of stool should you most expect? 1) Green-black, tarry, sticky, and odorless 2) Yellow-green 3) Golden yellow 4) Tan
3) Golden yellow
Which of the following most accurately describes nursing diagnoses? A nursing diagnosis: 1) Supports the nurse's diagnostic reading 2) Supports the patient's medical diagnosis 3) Identifies a patients response to a health issue 4) Identifies a patients health problem
3) Identifies a patients response to a health issue
You are working with a female client who weighs 110 pounds and is 65 inches tall. Based on her body mass index, which of the following classifications applies to this client? 1) Severely underweight 2) Moderately underweight 3) Mildly underweight 4) Healthy weight
3) Mildly underweight
What is the most influential factor that has shaped the nursing profession? 1) Physician's need for handmaidens 2) Societal need for healthcare outside the home 3) Military demand for nurses in the field 4) Germ theory influence on sanitation
3) Military demand for nurses in the field
Which of the following is the most important reason for nurses to be critical thinkers? 1) Nurses need to follow policies and procedures 2) Nurses work with other healthcare professionals 3) Nurses care for patients with multiple health issues 4) Nurses have to be flexible and work different schedules
3) Nurses care for patients with multiple health issues Nurses use critical thinking to care for them.
Where should the nurse assess skin color changes in the dark-skinned patient? 1) Nailbeds 2) Any exposed area 3) Oral mucosa 4) Palm of hands
3) Oral Mucosa
You are flexing and extending a client's forearm at the elbow as far as it will comfortably go without any assistance from the client. This activity is known as which of the following? 1) Body alignment 2) Line of gravity 3) Passive range of motion 4) Active range of motion
3) Passive range of motion
Who is the primary decision maker when caring for healthy adult clients? 1) Physician 2) Family 3) Patient 4) Nurse
3) Patient The patient is the primary decision maker.
You are working with a client who claims to be constipated and who uses laxatives and enemas daily to ensure that she has a bowel movement. Which of the following nursing diagnoses would be most appropriate for this client? 1) Constipation 2) Risk for Constipation 3) Perceived Constipation 4) Dysfunctional Gastrointestinal Motility
3) Perceived Constipation
The nurse is instructing a client how to appropriately dress an infant in cold weather. Which of the following instructions would be most appropriate for the nurse to include? 1) Be sure to put mittens on the baby 2) Layer the infant's clothing 3) Place a cap on the baby's head 4) Put warm booties on the baby
3) Place a cap on the baby's head Most heat is lost through the head.
You are caring for a patient who has a chest tube and a water-seal drainage system. The end of the chest tube is inserted into which of the following? 1) Bronchi 2) Lung 3) Pleural space 4) Trachea
3) Pleural space
Chest percussion and postural drainage would be appropriate intervention for which of the following conditions? 1) COPD 2) CHF 3) Pneumonia 4) Pulmonary embolism
3) Pneumonia
According to Maslow's hierarchy of needs, which patient need should the nurse address first? 1) Protecting against falls. 2) Protecting the patient from an abusive spouse 3) Promoting rest in the critically ill patient 4) Promoting self-esteem after a body image change
3) Promoting rest in the critically ill patient Basic physiological needs should be met first, which include the need for rest, food, air, temperature regulation, elimination, sex, and physical activity.
One of your clients, a 5-year-old boy, sleeps restlessly at night in his hospital room and scratches around his anal area incessantly. You suspect that he might have pinworms. Which of the following actions should you take to confirm this suspicion? 1) Perform a fecal occult blood test at the patient's bedside. 2) Notify the primary care provider and prepare the patient for an x-ray of the abdomen. 3) Spread the child's buttocks while he is sleeping and visually examine for the worms. 4) Notify the primary care provider and prepare the patient for endoscopy by a gastroenterologist.
3) Spread the child's buttocks while he is sleeping and visually examine for the worms.
A client explains that she has begun to "wet herself" when she laughs too hard or sneezes. Which type of incontinence is this an example of? 1) Urge incontinence 2) Functional incontinence 3) Stress incontinence 4) Reflex incontinence
3) Stress incontinence
A client coughs up some rust-colored sputum. Which of the following conditions should you most suspect based on this finding? 1) Viral infection 2) Pulmonary edema 3) Tuberculosis 4) Soot inhalation
3) Tuberculosis
A patient who moved to the US from Italy comes to the clinic for medical care. The patient has been in this country for several years and has adopted some elements of her new country. Yet still retains some customs from her homeland. This patient is experiencing: 1) assimilation 2) socialization 3) acculturation 4) immigration
3) acculturation
Mr. Jackson is terminally ill with metastatic cancer of the colon. His family notices that he is suddenly more focused and coherent. They are questioning whether he is really going to die. The nurse recognizes that a sudden urge of activity may occur: 1) 1 to 3 months before death 2) 1 to 2 weeks before death 3) days to hours before death 4) moments before death
3) days to hours before death
Which of the following would be a priority for most adolescents? Being ________________ 1) a good student 2) sexually active 3) picked to be on the soccer team 4) able to function independently
3) picked to be on the soccer team The developmental task during adolescence is to establish personal identity. Teens are driven to belong to a group.
What is the function of the stratum corneum? 1) provides insulation 2) provides strength and elasticity 3) protects the body against entry of pathogens 4) produces new skin cells
3) protects the body against entry of pathogens
In the following examples, which nurses are making nursing diagnostic errors? (Select all that apply) [17] 1. The nurse who listens to lung sounds after a patient reports "difficulty breathing" 2. The nurse who considers conflicting cues in deciding which diagnostic label to choose 3. The nurse assessing the edema in a patient's lower leg who is unsure how to assess the severity of edema 4. The nurse who identifies a diagnosis on the basis of a single defining characteristic
3, 4
The nurse check the IV solution that is infusing into the patient's left arm. The IV solution of 9% NS is infusing at 100 mL/hr as ordered. The nurse reviews the nurses' notes from the previous shift to determine if the dressing over the site what changed as scheduled per standard of care. While in the room, the nurse inspects the condition of the dressing and notes the date on the dressing label. In what ways did the nurse evaluate the IV intervention? (Select all that apply) [20] 1. Checked the IV infusion location in left arm 2. Checked the type of IV solution 3. Confirmed from nurses' notes the time of dressing change and checked label 4. Inspected the condition of the IV dressing
3, 4
A physician writes an order to apply a wrist restraint to a patient who has been pulling out a surgical wound drain. Place the following steps for applying the restraint in the correct order. [27] 1. Explain what you plan to do 2. Wrap a limb restraint around a wrist or ankle with soft part toward skin and secure 3. Determine that restraint alternatives fail to ensure the patient's safety 4. Identify the patient using proper identifier 5. Pad the patient's wrist
3, 4, 1, 5, 2
Put the following steps for removal of protective barriers after leaving an isolation room in order: [28] 1. Untie top, then bottom mask strings and remove from face 2. Untie waist and neck strings of gown. Allow gown to fall from shoulders and discard. Remove gown, rolling it onto itself without touching the contaminated side 3. Remove gloves 4. Remove eyewear or goggles 5. Perform hand hygiene
3, 4, 2, 1, 5
You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke and a recent fall. The wife stated that he has a history of high blood pressure, which is controlled by an antihypertensive and a diuretic. Currently he exhibits left-sided neglect and problems with spatial and perceptual abilities and is impulsive. He has moderate left-sided weakness that requires the assistance of two and the use of a gait belt to transfer to a chair. He currently has an IV line and a urinary catheter in place. What factors increase his fall risk at this time? (Select all that apply) [27] 1. Smokes a pack a day 2. Used a cane to walk at home 3. Takes antihypertensives and diuretics 4. History of recent fall 5. Neglect, spatial and perceptual abilities, impulsive 6. Requires assistance with activity, unsteady gait 7. IV line, urinary catheter
3, 4, 5, 6, 7
Which age-related change should the nurse consider when formulating a plan of care for an older adult? Select all that apply. Incorrect 1 Difficulty in swallowing 2 Increased sensitivity to heat 3 Increased sensitivity to glare 4 Diminished sensation of pain 5 Heightened response to stimuli .
3,4 Changes in the ciliary muscles, decrease in pupil size, and a more rigid pupil sphincter contribute to an increased sensitivity to glare. Diminished sensation of pain may make an older individual unaware of a serious illness, thermal extremes, or excessive pressure. There should be no interference with swallowing in older individuals. Older individuals tend to feel the cold and rarely complain of the heat. There is a decreased response to stimuli in the older individual
Below are the steps for administering oxygen via a nasal cannula. Put them in the correct order. 1. Turn on the oxygen using the flow meter, and adjust according to the prescribed flow rate. 2. Assess the patient's respiratory status. 3. Attach the flow meter to the oxygen source. 4. Assemble and apply the nasal cannula. 5. Check that the oxygen equipment is set up correctly and functioning properly.
3. Attach the flow meter to the oxygen source. 4. Assemble and apply the nasal cannula. 1. Turn on the oxygen using the flow meter, and adjust according to the prescribed flow rate. 5. Check that the oxygen equipment is set up correctly and functioning properly. 2. Assess the patient's respiratory status.
Below are the step-by-step instructions for collecting a clean-catch urine specimen from a male client. Put them in the correct order. 1. Allow the flow of urine to pass into the toilet. 2. Do not touch the inside of the container or allow pubic hair in the urine sample. 3. Have the client wash the end of the penis with antiseptic solution. 4. Place the lid on the container. 5. Ask the client to begin voiding. 6. Transport the specimen to the laboratory as soon as possible. 7. Collect a 30- to 60-mL specimen of urine in a container. 8. Label the container with the patient's name, the date, and the time of collection.
3. Have the client wash the end of the penis with antiseptic solution. 5. Ask the client to begin voiding. 1. Allow the flow of urine to pass into the toilet. 7. Collect a 30- to 60-mL specimen of urine in a container. 2. Do not touch the inside of the container or allow pubic hair in the urine sample. 4. Place the lid on the container. 8. Label the container with the patient's name, the date, and the time of collection. 6. Transport the specimen to the laboratory as soon as possible.
obese BMI
30 +
An intravenous piggyback (IVPB) of cefazolin (Kefzol) 500 mg in 50 mL of 5% dextrose in water is to be administered over a 20-minute period. The tubing has a drop factor of 15 drops/mL. At what rate per minute should the nurse regulate the infusion to run? Record the answer using a whole number. ______ gtts/min Solve the problem by using the following formula: Drops per minute = total number of drops / total time in minutes Drops per minute = 50 mL x 15 (drop factor) / 20 mintes = 750 / 20 = 37.5. Round the answer to 38 drops per minute.
38 Solve the problem by using the following formula: Drops per minute = total number of drops / total time in minutes Drops per minute = 50 mL x 15 (drop factor) / 20 mintes = 750 / 20 = 37.5. Round the answer to 38 drops per minute
A client receiving steroid therapy states, "I have difficulty controlling my temper which is so unlike me, and I don't know why this is happening." What is the nurse's best response? 1 Tell the client it is nothing to worry about. 2 Talk with the client further to identify the specific cause of the problem. 3 Instruct the client to attempt to avoid situations that cause irritation. 4 Interview the client to determine whether other mood swings are being experienced.
4
A couple is with their adolescent daughter for a school physical and state they are worries about all the saftey risks affecting this age. What is the greatest risk for injury to an adolescent? [27] 1. Home accidents 2. Physiological changes of aging 3. Poisoning and child abduction 4. Automobile accidents, suicide, and substance abuse
4
A nurse accidentally gives a patient a medication at the wrong time. The nurse's first priority is to: [31] 1. Complete an occurence report 2. Notify the healthcare provider 3. Inform the charge nurse of the error 4. Assess the patient for adverse effects
4
A nurse is administering eardrops to an 8-year-old patient with an ear infection. How does the nurse pull the patient's ear when administering the medication? [31] 1. Outward 2. Back 3. Upward and back 4. Upward and outward
4
A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is "diarrhea related to intestinal colitis." This is an incorrectly stated diagnostic statement, best described as: [17] 1. Identifying the clinical sign instead of an etiology 2. Identifying a diagnosis based on prejudicial judgment 3. Identifying the diagnostic study rather than a problem caused by the diagnostic study 4. Identifying the medical diagnosis instead of the patient's response to the diagnosis.
4
A patient has the nursing diagnosis of "nausea." The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions? [18] 1. Provide frequent mouth care 2. Maintain IV infusion at 100 mL/hr 3. administer prochlorperazine (Compazine) via rectal suppository 4. Consult with dietician on initial foods to offer patient 5. Control aversive odors or unpleasant visual stimulation that triggers nausea
4
A patient is to receive cephalexin (Keflex) 500 mg PO. The pharmacy has sent 250-mg tablets. How many tablets does the nurse administer? [31] 1. 1/2 tablet 2. 1 tablet 3. 1 1/2 tablets 4. 2 tablets
4
A woman who is a Jehovah's Witness has severe, life-threatening injuries and is hemorrhaging following a car accident. The healthcare provider ordered 2 units of packed red blood cells to treat the woman's anemia. The woman's husband refuses to allow the nurse to give his wife the blood. What is the nurse's responsibility? [23] 1. Obtain a court order to give the blood 2. Coerce the husband into giving the blood 3. Call security and have the husband removed from the hospital 4. Abide by the husband's wishes and inform the healthcare provider
4
Setting a time frame for outcomes of care serves which of the following purposes? [18] 1. Indicates which outcome has priority 2. Indicates the time it takes to complete an intervention 3. Indicates how long a nurse is schedules to care for a patient 4. Indicates when the patient is expected to respond in the desired manner
4
The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit. The nurse applies a cooling blanket and administers an antipyretic medication. The nurse explains that the rationale for these interventions is to: 1 Promote equalization of osmotic pressures. 2 Prevent hypoxia associated with diaphoresis. 3 Promote integrity of intracerebral neurons. 4 Reduce brain metabolism and limit hypoxia.
4
The nurse is caring for a non-ambulatory client with a reddened sacrum that is unrelieved by repositioning. What nursing diagnosis should be included on the client's plan of care? 1 Risk for pressure ulcer 2 Risk for impaired skin integrity 3 Impaired skin integrity, related to infrequent turning and repositioning 4 Impaired skin integrity, related to the effects of pressure and shearing force
4
The nurse wears a gown when: [28] 1. The patient's hygiene is poor 2. The nurse is assisting with medication administration 3. The patient has AIDS or hepatitis 4. Blood or body fluids may get onto the nurse's clothing from a task that he or she plans to perform
4
The nurse writes an expected-outcome statement in measurable terms. An example is: [18] 1. Patient will be pain free 2. Patient will have less pain 3. Patient will take pain medication every 4 hours 4. Patient will report pain acuity less than 4 on a scale of 0 to 10.
4
The nursing assessment on a 78-year-old woman reveals shuffling gait, decreased balance, and instability. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of the assessment findings? [27] 1. Activity intolerance 2. Impaired bed mobility 3. Acute pain 4. Risk for falls
4
The patient has an order for 2 tablespoons of Milk of Magnesia. How much medication does the nurse give him or her? [31] 1. 2 mL 2. 5 mL 3. 16 mL 4. 30 mL
4
Which is the most likely means of transmitting infection between patients? [28] 1. Exposure to another patient's cough 2. Sharing equipment between patients 3. Disposing of soiled linen in a shared linen bag 4. Contact with a health care worker's hands
4
A health care provider prescribes 10 mL of a 10% solution of calcium gluconate for a client with a severely depressed serum calcium level. The client also is receiving digoxin (Lanoxin) 0.25 mg daily and an intravenous (IV) solution of D5W. The nurse's next action is based on the fact that calcium gluconate: 1 Can be added to any IV solution Incorrect2 Must be administered via an intravenous piggyback (IVPB) 3 Is non-irritating to surrounding tissues Correct4 Potentiates the action of the digoxin preparation
4 Toxicity can result because the action of calcium ions is similar to that of digoxin. Calcium gluconate cannot be added to a solution containing carbonate or phosphate because a dangerous precipitation will occur. Calcium gluconate can be added to the IV solution the client is receiving. If calcium infiltrates, sloughing of tissue will result.
A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer? 1 Stage I 2 Stage II 3 Stage III 4 Unstageable
4 A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the wound can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A stage II pressure ulcer is a partial-thickness wound with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage III pressure ulcer involves full thickness tissue loss with visible subcutaneous fat. Bone, tendon, and muscle are not exposed.
What is the maximum length of time a nurse should allow an intravenous (IV) bag of solution to infuse? 1 6 hours 2 12 hours 3 18 hours 4 24 hours
4 After 24 hours there is increased risk for contamination of the solution and the bag should be changed. It is unnecessary to change the bag any less often.
A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the nurse question? 1 Oral psyllium (Metamucil) 2 Oral potassium supplement 3 Parenteral half normal saline 4 Parenteral albumin (Albuminar)
4 Albumin is hypertonic and will draw additional fluid from the tissues into the intravascular space. Oral psyllium will absorb the watery diarrhea, giving more bulk to the stool. An oral potassium supplement is appropriate because diarrhea causes potassium loss. Parenteral half normal saline is a hypotonic solution, which can correct dehydration.
To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the nurse should change the administration set every: 1 4 to 8 hours 2 12 to 24 hours 3 24 to 48 hours 4 72 to 96 hours
4 Best practice guidelines recommend replacing administration sets no more frequently than 72 to 96 hours after initiation of use in patients not receiving blood, blood products, or fat emulsions. This evidence-based practice is safe and cost effective. Changing the administration set every 4 to 48 hours is not a cost-effective practice
A dying client is coping with feelings regarding impending death. The nurse bases care on the theory of death and dying by Kübler-Ross. During which stage of grieving should the nurse primarily use nonverbal interventions? 1 Anger 2 Denial 3 Bargaining 4 Acceptance
4 Communication and interventions during the acceptance stage are mainly nonverbal (e.g., holding the client's hand). The nurse should be quiet but available. During the anger stage the nurse should accept that the client is angry. The anger stage requires verbal communication. During the denial stage the nurse should accept the client's behavior but not reinforce the denial. The denial stage requires verbal communication. During the bargaining stage the nurse should listen intently but not provide false reassurance. The bargaining stage requires verbal communication.
A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the nurse give the client about this medication? 1 Prolonged use can cause dark concentrated urine. 2 The medication is best absorbed when taken on an empty stomach. 3 Take the medication with aluminum hydroxide to minimize GI upset. 4 Drinking alcohol daily can cause drug-induced hepatitis
4 Daily alcohol intake can cause drug induced hepatitis. Prolonged use does not cause dark concentrated urine. The client should take isoniazid with meals to decrease GI upset. Clients should avoid taking aluminum antacids at the same time as this medication because it impairs absorption.
A visitor comes to the nursing station and tells the nurse that a client and his relative had a fight and that the client is now lying unconscious on the floor. What is the most important action the nurse needs to take? 1 Ask the client if he is okay. 2 Call security from the room. 3 Find out if there is anyone else in the room. 4 Ask security to make sure the room is safe
4 Safety is the first priority when responding to a presumably violent situation. The nurse needs to have security enter the room to ensure it is safe. Then it can be determined if the client is okay and make sure that any other people in the room are safe
The spouse of a comatose client who has severe internal bleeding refuses to allow transfusions of whole blood because they are Jehovah's Witnesses. The client does not have a Durable Power of Attorney for Healthcare. What action should the nurse take? 1 Institute the prescribed blood transfusion because the client's survival depends on volume replacement. 2 Clarify the reason why the transfusion is necessary and explain the implications if there is no transfusion. 3 Phone the health care provider for an administrative prescription to give the transfusion under these circumstances. 4 Give the spouse a treatment refusal form to sign and notify the health care provider that a court order now can be sought
4 The client is unconscious. Although the spouse can give consent, there is no legal power to refuse a treatment for the client unless previously authorized to do so by a power of attorney or a health care proxy; the court can make a decision for the client. Explanations will not be effective at this time and will not meet the client's needs. Instituting the prescribed blood transfusion and phoning the health care provider for an administrative prescription are without legal basis, and the nurse may be held liable.
Following a surgery on the neck, the client asks the nurse why the head of the bed is up so high. The nurse should tell the client that the high-Fowler position is preferred for what reason? 1 To avoid strain on the incision 2 To promote drainage of the wound 3 To provide stimulation for the client 4 To reduce edema at the operative site
4 This position prevents fluid accumulation in the tissue, thereby minimizing edema. This position will neither increase nor decrease strain on the suture line. Drainage from the wound will not be affected by this position. This position will not affect the degree of stimulation.
A nurse in the surgical intensive care unit is caring for a client with a large surgical incision. The nurse reviews a list of vitamins and expects that which medication will be prescribed because of its major role in wound healing? 1 Vitamin A (Aquasol A) 2 Cyanocobalamin (Cobex) 3 Phytonadione (Mephyton) 4 Ascorbic acid (Ascorbicap)
4 Vitamin C (ascorbic acid) plays a major role in wound healing . It is necessary for the maintenance and formation of collagen, the major protein of most connective tissues. Vitamin A is important for the healing process; however, vitamin C is the priority because it cements the ground substance of supportive tissue. Cyanocobalamin is a vitamin B12 preparation needed for red blood cell synthesis and a healthy nervous system. Phytonadione is vitamin K, which plays a major role in blood coagulation.
The nurse plans care for a client with a somatoform disorder based on the understanding that the disorder is: 1 A physiological response to stress 2 A conscious defense against anxiety 3 An intentional attempt to gain attention 4 An unconscious means of reducing stress
4 When emotional stress overwhelms an individual's ability to cope, the unconscious seeks to reduce stress. A conversion reaction removes the client from the stressful situation, and the conversion reaction's physical/sensory manifestation causes little or no anxiety in the individual. This lack of concern is called la belle indifference. No physiologic changes are involved with this unconscious resolution of a conflict. The conversion of anxiety to physical symptoms operates on an unconscious level.
You are teaching a group of older adults in a senior center about the hazards of carbon monoxide poisoning and methods to prevent it. Which of the following interventions should you mention related to this hazard? 1) Avoid smoking in the home. 2) Avoid exposing oxygen administration equipment to an open flame. 3) Avoid contact with clothing contaminated by toxins from industrial workplaces. 4) Avoid using your gas range to heat your home.
4) Avoid using your gas range to heat your home.
The nurse notes that an electrical cord on an IV pump is cracked. Which action by the nurse is the best? 1) Continue to monitor the IV pump to see if the crack worsens. 2) Place the pump back in the utility room. 3) Continue using the pump. 4) Clearly label the pump and send it for repair
4) Clearly label the pump and send it for repair Whenever an electrical safety hazard is suspected or visible, label it and send it for repair.
The process whereby blood pressure forces plasma, dissolved substances, and small proteins out of the porous glomeruli into Bowman's capsule while large molecules, such as blood cells and blood proteins, are held back is known as which of the following? 1) Tubular reabsorption 2) Tubular secretion 3) Excretion 4) Filtration
4) Filtration
A patient tells the nurse, "I can't see well enough to read anymore. I have new glasses but it is still hard." What should the nurse advise the patient to do first? 1) Go back to the eye doctor and have the glasses checked. 2) Buy some audio books and listen to those. 3) Adapt to reading less. 4) Install a bright, but glare-free light near where you read.
4) Install a bright, but glare-free light near where you read. With aging, there is also sensitivity to glare, so the light should be glare-free. Patient should try this first, since the glasses are new.
To which age group do most hospitalized patients belong? 1) Infants 2) Young adults 3) Middle adults 3) Older adults
4) Older adults. Half of all hospitalized patients are older adults.
A patient with end-stage cancer is prescribed morphine to reduce pain. For which effect is this medication prescribed? 1) Supportive 2) Restorative 3) Substitutive 4) Palliative
4) Palliative
You are caring for a client who has developed a bone spur in her first vertebra (the atlas), which limits the movement in her atlantoaxial joint. Which type of joint is this? 1) Ball-and-socket 2) Condyloid 3) Hinge 4) Pivot
4) Pivot
Which action should the nurse take to relax the vastus lateralis muscle before administering an IM injection into this site? 1) Apply a warm compress 2) Massage the site in a circular motion 3) Apply a soothing lotion 4) Put the patient in a sitting position
4) Put the patient in a sitting position
In caring for a client who has a fever, it would be most important for the nurse to monitor for increased: 1) urine output 2) sensitivity to pain 3) blood pressure 4) respiratory rate
4) Respiratory rate
You provide home nursing care to an older client who lives alone in a cluttered apartment and who has macular degeneration. You are concerned that the client may fall while at home alone. Which of the following nursing diagnoses would be most appropriate? 1) Risk for Falls related to poor vision and a cluttered home environment 2) Risk for falls related to environmental and physical factors 3) Risk for Falls related to a sensory problem and environment 4) Risk for Falls related to a cluttered home environment and poor vision secondary to macular degeneration
4) Risk for Falls related to a cluttered home environment and poor vision secondary to macular degeneration
Which factor is held in common by many of the world religions? 1) Strict health code, including dietary laws 2) Belief that one must submit to a god or gods. 3) Rules prohibiting alcohol consumption. 4) Sacred writings that reveal the nature of the Supreme Being
4) Sacred writings that reveal the nature of the Supreme Being Sacred writings that reveal the nature of a Supreme Being are common in world religions.
Which of the following is an example of data that should be validated? 1) The patient's weight is 185 lbs at the clinic 2) The patient's liver function test is elevated 3) The patients blood pressure if 160/90: he says that is normal for him 4) The patient says she eats a low sodium diet: later describes eating fast foods
4) The patient says she eats a low sodium diet: later describes eating fast foods Validate the patient says she eats a low sodium diet but describes eating fast food that is not low in sodium.
You are caring for a client who has had an opening surgically made directly into the trachea to bypass an airway obstruction and permit an open airway. Which of the following airway types is this? 1) Nasopharyngeal 2) Orotracheal 3) Nasotracheal 4) Tracheostomy
4) Tracheostomy
You are a member of a sports medicine team that works with U.S. Olympic track and field athletes. Precise measurement of the body composition of the athletes is critical to maximizing their performance. Which method of measuring body composition would be best for this application? 1) Skinfold measurements 2) Body mass index (BMI) calculation 3) Computed tomography (CT) 4) Underwater weighing
4) Underwater weighing
The nurse is talking to a class of children ages 9-12. For this group, it would be most important for the nurse to discuss______. 1) Safe sex practices 2) Healthy food choices 3) Importance of getting enough sleep 4) Use of seat belts and safety equipment
4) Use of seat belts and safety equipment Children of this age group are very active and injuries are common. Motor vehicle accidents are the most common cause of injury.
A patient infected with a virus but who does not have any outward signs of the disease is considered a: 1) pathogen 2) fomite 3) vector 4) carrier
4) carrier Carriers have no outward signs of active disease, yet they can pass the infection to others.
The primary care provider prescribes furosemide 40 mg IV for the patient with CHF. Which drug name is used in this order? 1) chemical 2) Brand 3) trade 4) generic
4) generic
Which of the following is a benefit of standardized care plans, as defined in your text? Standardized care plans: 1) apply to every patient on a particular unit 2) included medical and nursing diagnoses 3) specify each patient outcomes for each day 4) help to ensure that important interventions are not overlooked.
4) help to ensure that important interventions are not overlooked.
While assisting an older adult patient, the nurse notes clubbing of the fingers. This is a sign of: 1) Fungal infection 2) Iron deficiency 3) Poor Hygiene 4) Long term hypoxia
4) long term hypoxia
Before administering medication, the nurse must verify the rights of medication administration which include: 1) right patient, right room, right drug, right route, right time 2) right drug, right dose, right route, right physician, right time 3) right patient, right drug, right route, right equipment, right time 4) right patient, right drug, right dose, right route, right time, right documentation
4) right patient, right drug, right dose, right route, right time, right documentation
The nurse follows a series of steps to objectively evaluate the degree of success in achieving outcomes of care. Place the steps in the correct order. [20] 1. The nurse judges the extent to which the condition of the skin matches the outcome criteria 2. The nurse tries to determine why the outcome criteria and actual condition of the skin do not agree 3. The nurse inspects the condition of the skin 4. The nurse reviews the outcome criteria to identify the desired skin condition 5. The nurse compares the degree of agreement between desired and actual condition of the skin
4, 3, 5, 1, 2
Below are the steps for performing upper airway suctioning (nasopharyngeal). Put them in the correct order. 1. Using your dominant hand, attach the suction catheter to the connection tubing. 2. Don procedure gloves. 3. Lubricate and insert the suction catheter. 4. Position the patient in a semi-Fowler's position with the neck hyperextended. 5. Gently advance the catheter the premeasured distance into the pharynx. 6. Engage the suction and apply it while you withdraw the catheter, using a continuous rotating motion. 7. Approximate the depth that the suction catheter should be inserted. 8. Adjust the suction regulator according to agency policy.
4. Position the patient in a semi-Fowler's position with the neck hyperextended. 8. Adjust the suction regulator according to agency policy. 2. Don procedure gloves. 1. Using your dominant hand, attach the suction catheter to the connection tubing. 7. Approximate the depth that the suction catheter should be inserted. 3. Lubricate and insert the suction catheter. 5. Gently advance the catheter the premeasured distance into the pharynx. 6. Engage the suction and apply it while you withdraw the catheter, using a continuous rotating motion.
Below are the steps for irrigating a colostomy. Put them in the correct order. 1. Prepare the new appliance and remove the existing one. 2. Remove the sleeve and rinse, dry, and store it. 3. Examine the stoma and peristomal skin. 4. Prime the tubing using 500 to 1,000 mL of warm tap water. 5. Allow approximately 30 minutes for evacuation. 6. Position the patient on the toilet. 7. Lubricate the cone at the end of the tubing and insert it gently.
4. Prime the tubing using 500 to 1,000 mL of warm tap water. 6. Position the patient on the toilet. 1. Prepare the new appliance and remove the existing one. 3. Examine the stoma and peristomal skin. 7. Lubricate the cone at the end of the tubing and insert it gently. 5. Allow approximately 30 minutes for evacuation. 2. Remove the sleeve and rinse, dry, and store it.
A nurse is preparing to administer dextrose 5% in lactated Ringer's (D5LR) 1000 mL to infuse over 6 hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should adjust the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Do not use a trailing zero).
42 gtt/min
integrity vs despair
65+
DVT's usually develop
7 to 10 days after surgery and are always asymptomatic
Below are the steps for transferring a patient from a bed to a wheelchair. Put them in the correct order. 1. Instruct the patient to place her arms around you between your shoulders and waist. 2. Place the bed in the low position and lock the wheels. 3. Instruct the patient to pivot and turn with you toward the wheelchair. 4. Ask the patient to stand as you move to an upright position by straightening your legs and hips. 5. Ask the patient to flex her hips and knees as she lowers herself to the wheelchair. Guide her motion while maintaining a firm hold on her. 6. Assist the patient to dangle at the side of the bed. 7. Lock the wheels of the wheelchair. 8. Brace your feet and knees against the patient, bend your hips at the knees, and hold on to the transfer belt.
7. Lock the wheels of the wheelchair. 2. Place the bed in the low position and lock the wheels. 6. Assist the patient to dangle at the side of the bed. 8. Brace your feet and knees against the patient, bend your hips at the knees, and hold on to the transfer belt. 1. Instruct the patient to place her arms around you between your shoulders and waist. 4. Ask the patient to stand as you move to an upright position by straightening your legs and hips. 3. Instruct the patient to pivot and turn with you toward the wheelchair. 5. Ask the patient to flex her hips and knees as she lowers herself to the wheelchair.
A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow?
8 a.m., 4 p.m., and midnight.
73.The charge nurse observes an unlicensed assistive personnel (UAP) bending at the waist to lift a 20-pound box of medical supplies off the treatment room floor. What instruction should the charge nurse provide to the UAP? A. Ask another staff member for assistance. B. Request that supplies are delivered in smaller containers. C. Push the box against the wall to provide support while lifting. D. Bend at the knees when lifting heavy objects.
A 20-pound box is safely lifted by bending the knees (D), holding the box close to the center of gravity, and extending the legs using the quadriceps muscles. (A and B) might be helpful, but the charge nurse should use this opportunity to reinforce proper body mechanics techniques. Pushing the box against the wall (C) does not assist with lifting. Correct Answer: D
30.As the nurse prepares the equipment to be used to start an IV on a 4-year-old boy in the treatment room, he cries continuously. What intervention should the nurse implement? A. Take the child back to his room. B. Recruit others to restrain the child. C. Ask the mother to be present to soothe the child. D. Show the child how to manipulate the equipment.
A 4-year-old typically has a vivid imagination and lacks concrete thinking abilities. The mother's assistance (C) can provide a stabilizing presence to help soothe the preschooler, who may perceive the invasive procedure as mutilating. To preserve the child's sense of security associated with the hospital room, it is best to perform difficult or painful procedures in another area (A). (B) may be necessary to prevent injury if the child is unable to cooperate with the mother's coaxing. (D) is best done before going to the treatment room when the child feels less threatened. Correct Answer: C
ealth care workers who have direct contact with individuals suspected of being contaminated with anthrax should do which of the following? (Choose all that apply.) A) Wear an isolation gown, gloves, and high-efficiency particle arrestor (HEPA) mask B) Prepare the client for transfer to the radiology department for chest radiography C) Instruct the client to wash the hands and exposed areas with soap and water D) Have the client remove clothing and place it in a sealed biohazard bag
A and D Anthrax is caused by a spore-forming, gram-positive bacillus. Humans become infected through skin contact, ingestion, and inhalation. The nurse should wear an isolation gown, gloves, and a high-efficiency particle arrestor (HEPA) mask. The client should remove potentially contaminated clothing for testing and decontamination. The client should remain in isolation until it is certain that the bacteria have been contained, not transferred to radiology. The client should shower thoroughly with soap and water, not just wash hands and exposed areas.
A client is experiencing nausea and abdominal distention postoperatively. The nurse initiates the interventions listed below. Which of the interventions is an example of an independent intervention? (Select all that apply.) A) Provides frequent mouth care B) Maintains intravenous infusion at 100 ml/hr C) Administers prochlorperazine (Compazine) via rectal suppository D) Consults with the dietitian on initial foods to offer the client E) Controls aversive odors and unpleasant visual stimulation that trigger nausea
A and E Providing frequent mouth care and controlling aversive odors and unpleasant visual stimulation that trigger nausea are examples of independent intervention. The other options are dependent interventions.
31.When making the bed of a client who needs a bed cradle, which action should the nurse include? A. Teach the client to call for help before getting out of bed. B. Keep both the upper and lower side rails in a raised position. C. Keep the bed in the lowest position while changing the sheets. D. Drape the top sheet and covers loosely over the bed cradle.
A bed cradle is used to keep the top bedclothes off the client, so the nurse should drape the top sheet and covers loosely over the cradle (D). A client using a bed cradle may still be able to ambulate independently (A) and does not require raised side rails (B). (C) causes the nurse to use poor body mechanics. Correct Answer: D
63.The nurse is preparing to give a client with dehydration IV fluids delivered at a continuous rate of 175 ml/hour. Which infusion device should the nurse use? A. Portable syringe pump. B. Cassette infusion pump. C. Volumetric controller. D. Nonvolumetric controller.
A cassette pump (B) should be used to accurately deliver large volumes of fluid over longer periods of time with extreme precise, such as ml/hour. A syringe pump (A) is accurate for low-dose continuous infusion of low-dose medication at a basal rate, but not large fluid volume replacement. Volumetric (C) and nonvolumetric (D) controllers count drops/minute to administer fluid volume and are inherently inaccurate because of variation in drop size. Correct Answer: B
A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? A. Administer the medication more rapidly using the same IV site. B. Initiate an alternate site for the IV infusion of the medication. C. Notify the healthcare provider before administering the next dose. D. Give the client a PRN dose of aspirin while the medication infuses.
A cephalosporin antibiotic that is administered IV may cause vessel irritation. Rotating the infusion site minimizes the risk of thrombophlebitis, so an alternate infusion site should be initiated (B) before administering the next dose. Rapid administration (A) of intravenous cephalosporins can potentiate vessel irritation and increase the risk of thrombophlebitis. (C) is not necessary to initiate an alternative IV site. Although aspirin has antiinflammatory actions, (D) is not indicated. Correct Answer: B
A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take? A. Explain that anyone who speaks her language can answer her questions. B. Provide a translator only in an emergency situation. C. Ask a family member or friend of the client to translate. D. Request and document the name of the certified translator.
A certified translator should be requested to ensure the exchanged information is reliable and unaltered. To adhere to legal requirements in some states, the name of the translator should be documented (D). Client information that is translated is private and protected under HIPAA rules, so (A) is not the best action. Although an emergency situation may require extenuating circumstances (B), a translator should be provided in most situations. Family members may skew information and not translate the exact information, so (C) is not preferred. Correct Answer: D
87.An older client who is able to stand but not to ambulate receives a prescription to be mobilized into a chair as tolerated during each day. What is the best action for the nurse to implement when assisting the client from the bed to the chair? A. Use a mechanical lift to transfer from the bed to a chair. B. Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair. C. Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three. D. Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed.
A client who can stand can safely be assisted to pivot and transfer with the use of a transfer belt (D). A mechanical lift (A) is usually used for a client who is obese, unable to be weight-bearing, and who is unable to assist. Roller boards (B) placed under a sheet are used to facilitate the transfer of a recumbent client who is being transferred to and from a stretcher. Lifting a client (C) out of bed places the client and nurses at risk for injury and should only be implemented by skilled lift teams. Correct Answer: D
17.To obtain the most complete assessment data for a client with chronic pain, which information should the nurse obtain? A. Can you describe where your pain is the most severe? B. What is your pain intensity on a scale of 1 to 10? C. Is your pain best described as aching, throbbing, or sharp? D. Which activities during a routine day are impacted by your pain?
A client with chronic pain is more likely to have adapted physiologically to vital sign changes, localization or intensity, so pain assessment should focus on any interference with daily activities (D), sleep, relationships with others, physical activity, and emotional well-being. Exacerbation of acute symptoms, such as pain distribution, patterns, intensity, and descriptors illicit specific assessment findings, whereas (A, B, and C) are limiting, closed-end questions, and can be answered with a yes, no, or a number. Correct Answer: D
What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults?
A decreased flow rate could result in the formation of a thrombosis.
Spasms in atrial (many pwaves), blood pools-- tx with anticoagulant (warfarin), cardizem, digoxin & cardiovert if symptoms present
A fib
The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A. A college-age track runner with a sprained ankle. B. A lactating woman nursing her 3-day-old infant. C. A school-aged child with Type 2 diabetes. D. An elderly man being treated for a peptic ulcer.
A lactating woman (B) has the greatest need for additional protein intake. (A, C, and D) are all conditions that require protein, but do not have the increased metabolic protein demands of lactation. Correct Answer: B
The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein?
A lactating woman nursing her 3-day-old infant.
12.A male client with an infected wound tells the nurse that he follows a macrobiotic diet. Which type of foods should the nurse recommend that the client select from the hospital menu? A. Low fat and low sodium foods. B. Combination of plant proteins to provide essential amino acids. C. Limited complex carbohydrates and fiber. D. Increased amount of vitamin C and beta carotene rich foods.
A macrobiotic diet is high in whole-grain cereals, vegetables, sea vegetables, beans, and vegetarian soups, and the client needs essential amino acids to provide complete proteins to heal the infected wound. Although a macrobiotic diet contains no source of animal protein, essential amino acids should be obtained by combining plant (incomplete) proteins to provide complete (all essential amino acids) proteins (B) for anabolic processes. (A, C, and D) do not provide the client with food choices consistent with a macrobiotic diet and protein needs. Correct Answer: B
Based on the Braden Risk Assessment Scales which client is at highest risk?
A male who is aphasic and experiencing bladder incontinence
Ketones accumulate in the blood and urine when fat breaks down. Ketones signal a deficiency of insulin that will cause the body to start to break down stored fat for energy. Explanation: Ketones (or ketone bodies) are byproducts of fat breakdown, and they accumulate in the blood and urine. Ketones in the urine signal a deficiency of insulin and control of type 1 diabetes is deteriorating. When almost no effective insulin is available, the body starts to break down stored fat for energy
A nurse is teaching a patient recovering from diabetic ketoacidosis (DKA) about management of "sick days." The patient asks the nurse why it is important to monitor the urine for ketones. Which of the following statements is the nurse's best response?
21.A client is demonstrating a positive Chvostek's sign. What action should the nurse take? A. Observe the client's pupil size and response to light. B. Ask the client about numbness or tingling in the hands. C. Assess the client's serum potassium level. D. Restrict dietary intake of calcium-rich foods.
A positive Chvostek's sign is an indication of hypocalcemia, so the client should be assessed for the subjective symptoms of hypocalcemia, such as numbness or tingling of the hands (B) or feet. (A and C) are unrelated assessment data. (D) is contraindicated because the client is hypocalcemic and needs additional dietary calcium. Correct Answer: B
Singular goal or outcome:
A singular goal or outcome is precise in evaluating a patient response to a nursing action; each goal and outcome should address only one behavior, perception, or physiologic response
While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? A) Acknowledge that she is supporting the arm correctly. B) Encourage her to keep the joint covered to maintain warmth. C) Reinforce the need to grip directly under the joint for better support. D) Instruct her to grip directly over the joint for better motion.
A) Acknowledge that she is supporting the arm correctly The wife is performing the passive ROM correctly, therefore the nurse should acknowledge this fact (A). The joint that is being exercised should be uncovered (B) while the rest of the body should remain covered for warmth and privacy. (C and D) do not provide adequate support to the joint while still allowing for joint movement
As a member of the hospital's bioterrorism team, the nurse understands the importance of knowing how an organism is transmitted. Smallpox has the potential to spread quickly because it is transmitted via which route? A) Airborne B) Ingestion C) Absorption D) Blood-borne
A) Airborne Organisms with an airborne route of transmission can claim many victims and spread very quickly. Smallpox is not spread via blood. There is no such thing as an absorption or ingestion route of transmission.
An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? A) Be sure to have a complete physical examination before beginning your planned exercise program. B) Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more. C) Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class. D) Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation.
A) Be sure to have a complete physical examination before beginning your planned exercise program The most important teaching is (A), so that the client will not begin a dangerous level of exercise when he is not sufficiently fit. This might result in chest pain, a heart attack, or stroke. (B, C, and D) are important instructions, but are of less priority than (A).
The nurse plans to obtain health assessment information from a primary source. Which option is a primary source for the completion of the health assessment? A) Client. B) Healthcare provider. C) A family member. D) Previous medical records
A) Client A primary source of information for a health assessment is the client (A). (B, C, and D) are considered secondary sources about the client's health history, but other details, such as subjective data, can only be provided directly from the client.
A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take? A) Commend the client for selecting a high biologic value protein. B) Remind the client that protein in the diet should be avoided. C) Suggest that the client also select orange juice, to promote absorption. D) Encourage the client to attend classes on dietary management of CRF
A) Commend the client for selecting a high biologic value protein Foods such as eggs and milk (A) are high biologic proteins which are allowed because they are complete proteins and supply the essential amino acids that are necessary for growth and cell repair. Although a low-protein diet is followed (B), some protein is essential. Orange juice is rich in potassium, and should not be encouraged (C). The client has made a good diet choice, so (D) is not necessary
After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A) Determine the etiology of the problem. B) Prioritize nursing care interventions. C) Plan appropriate interventions. D) Collaborate with the client to set goals.
A) Determine the etiology of the problem Before planning care, the nurse should determine the etiology, or cause, of the problem (A), because this will help determine (B, C, and D).
The nurse is using a genogram while conducting a client's health assessment and past medical history. What information should the genogram provide? A) Genetic and familial health disorders. B) Chronic health problems. C) Reason for seeking health care. D) Undetected disorders.
A) Genetic and familial health disorders A genogram that is used during the health assessment process identifies genetic and familial health disorders (A). It may not identify the client's chronic health problems (B), so it is not a reason to seek health care (C). A genogram is not a diagnostic tool to detect disorders (D), such as those based on pathological findings or DNA.
An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? A) It is important that you continue your medication while learning to meditate. B) Spiritual meditation requires a time commitment of 15 to 20 minutes daily. C) Obtain your healthcare provider's permission before starting meditation. D) Complementary therapy and western medicine can be effective for you.
A) It is important that you continue your medication while learning to meditate The prolonged practice of meditation may lead to a reduced need for antihypertensive medications. However, the medications must be continued (A) while the physiologic response to meditation is monitored. (B) is not as important as continuing the medication. The healthcare provider should be informed, but permission is not required to meditate (C). Although it is true that this complimentary therapy might be effective (D), it is essential that the client continue with antihypertensive medications until the effect of meditation can be measured
During the daily nursing assessment, a client begins to cry and states that the majority of family and friends have stopped calling and visiting. What action should the nurse take? A) Listen and show interest as the client expresses these feelings. B) Reinforce that this behavior means they were not true friends. C) Ask the healthcare provider for a psychiatric consult. D) Continue with the assessment and tell the client not to worry.
A) Listen and show interest as the client expresses these feelings When a client begins to cry and express feelings, a therapeutic nursing intervention is to listen and show interest as the client expresses feelings (A). (B) is not therapeutic option and the nurse does not know the dynamics of their relationships. (C) is not indicated at this time. (D) is non-therapeutic and offers false hope
The most effective way to break the chain of infection is by: A) Practicing good hand hygiene B) Wearing gloves C) Placing clients in isolation D) Providing private rooms for clients
A) Practicing good hand hygiene Good hand hygiene is the most effective way to break the chain of infection. Wearing gloves can help in decreasing disease transmission, but clean hands are required for it to be truly effective. Placing clients in isolation is costly and often unnecessary, and clients can be psychologically harmed by isolation. Even providing private rooms for clients will not be effective if health care workers do not follow good hand hygiene practices.
A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment? A) What is your daily calorie consumption? B) What vitamin and mineral supplements do you take? C) Do you feel that you are overweight? D) Will a clear liquid diet be okay after surgery?
A) What is your daily calorie consumption? Vitamin and mineral supplements (B) may impact medications used during the operative period. (A and C) are appropriate questions for long-term dietary counseling. The nature of the surgery and anesthesia will determine the need for a clear liquid diet (D), rather than the client's preference
A nurse in a provider's office is preparing to auscultate and percuss a client's abdomen as a part of a comprehensive physical examination. Which of the following findings should the nurse expect? Select all that apply. a. Tympany b. High-pitched clicks c. Borborygmi d. Friction rubs e. Bruits
A, B
A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? Select all that apply a. Make sure the surgeon obtained the client's consent b. Witness the client's signature on the consent form c. Explain the risks and benefits of the procedure d. Describe the consequences of choosing not to have the surgery e. Tell the client about alternatives to having the surgery
A, B
A nurse is performing a neurosensory examination of a client. Which of the following assessments should the nurse perform to test the client's balance? Select all that apply. a. Romberg test b. Hell-to-toe walk c. Snellen d. Spinal accessory function e. Rosenbaum test
A, B
A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform before beginning the procedure? Select all that apply. a. Review a signal the client can use if feeling any distress b. Lay a towel across the client's chest c. Administer oral pain medication d. Obtain a Dobhoff tube for insertion e. Have a petroleum-based lubricant available
A, B
A nurse in a provider's office is documenting his findings following an examination he performed for a client new to the practice. Which of the following parameters should he include as part of the general survey? Select all that apply. a. Posture b. Skin lesions c. Speech d. Allergies e. Immunization status
A, B, C
A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? Select all that apply. a. Older adults are more prone to dehydration than young adults are b. Older adults need the same amount of most vitamins and minerals as younger adults do c. Many older men and women need calcium supplementation d. Older adults need more calories than they did when they were younger e. Older adults should consume a diet low in carbohydrates
A, B, C
A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? Select all that apply. a. Ausculatate bowel sounds b. Assist the client to an upright position c. Test the pH of gastric aspirate d. Warm the formula to body temperature e. Discard any residual gastric contents
A, B, C
A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? Select all that apply. a. Apply the oxygen source loosely if the SpO2 decreases during procedure b. Use surgical asepsis to remove and clean the inner cannula c. Clean the outer surfaces in a circular motion form stoma site outward d. Replace the tracheostomy ties with new ties e. Cut a slit in gauze squares to place beneath the tube holder
A, B, C
A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? Select all that apply. a. Increase in incisional pain b. Fever and chills c. Reddened wound edges d. Increase in serosanguineous drainage e. Decrease in thirst
A, B, C
A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care setting should the nurse classify as tertiary care? Select all that apply. a. Intensive care unit b. Oncology treatment center c. Burn center d. Cardiac rehabilitation e. Home health care
A, B, C
A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? Select all that apply. a. Place the client in semi-Fowler's position b. Have the client rest an arm across the abdomen c. Observe one full respiratory cycle before counting the rate d. Count the rate for 30 seconds if it is irregular e. Count and report any sighs the client demonstrates
A, B, C
A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following steps should the nurse take? Select all that apply. a. Warm the enema solution prior to instillation b. Position the client on the left side with the right leg flexed forward c. Lubricate the rectal tube or nozzle d. Slowly insert the rectal tube about 5 cm (2 in) e. Hang the enema container 61 cm (24 in) above the client's anus
A, B, C
A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? Select all that apply a. Repeat the details of the prescription back to the provider b. Have another nurse listen to the telephone prescription c. Obtain the provider's signature on the prescription within 24 hrs d. Decline the verbal prescription because it is not an emergency situation e. Tell the charge nurse that the provider has prescribed morphine by telephone
A, B, C
A nurse is preparing a wellness presentation for families about health screening for adolescents. Which of the following information should the nurse include? Select all that apply. a. Obtain a periodic mental status evaluation b. Discuss prevention of sexually transmitted infections c. Regularly screen for tuberculosis d. Provide education about drug and alcohol use e. Teach monthly breast examinations for girls
A, B, C, D
7. Which steps do you follow when you are asked to perform a procedure about which you are unfamiliar? Select all that apply. A) Seek necessary knowledge B) Reassess the client's condition C) Collect all equipment necessary D) Have an experienced nurse available to assist E) Consider all possible consequences of the procedure
A, B, C, D, and E Each of the five options is important in performing a new procedure. Be sure to seek all necessary knowledge, consider the possible consequences of the procedure, reassess the patient, collect the appropriate supplies, and ask a nurse experienced in the procedure to help out
A client newly admitted to the hospital begins to have chest pain. Before calling the physician, the nurse should gather what additional data? (Select all that apply.) A) Pain intensity B) Location of pain C) Character of pain D) Radiation of pain E) Meaning of pain to the client F) Family history of myocardial infarctions
A, B, C, D, and E The nurse should gather the data the physician will need to determine whether the chest pain represents a myocardial infarction. Family history is important in comprehensive pain assessment; however, taking time to obtain this information is inappropriate in this critical situation.
A nurse in a clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors for cardiovascular disease. Which of the following should the nurse include? Select all that apply. a. Help the client see the benefits of her actions b. Identify the client's support systems c. Suggest and recommend community resources d. Devise and set goals for the client e. Teach stress management strategies
A, B, C, E
A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will encounter on a medical-surgical unit. When she gives examples of the types of task certified nursing assistants (CNAs) may perform, which of the following client activities should she include? Select all that apply a. Bathing b. Ambulating c. Toileting d. Determining pain level e. Measuring vital signs
A, B, C, E
A nurse is admitting a client who has acute cholecystitis to a medical-surgical unit. Which of the following actions are essential steps of the admission procedure? Select all that apply. a. Explain the roles of other care delivery staff b. Begin discharge planning c. Provide information about advance directives d. Document the client's wishes about organ donation e. Introduce the client to his roommate
A, B, C, E
A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? Select all that apply a. Planing and evaluating control and prevention strategies b. Determining public health priorities c. Ensuring proper medical treatment d. Identifying endemic disease e. Monitoring for common-source outbreaks
A, B, C, E
A nurse is planning a health promotion and primary prevention class for the parents of school-age children. Which of the following information should the nurse include? Select all that apply. a. Provide information about the risk of childhood obesity b. Discuss the danger of substance use disorders c. Promote discussion about sexual issues d. Recommend the school-age child sit in the front seat of the car e. Reinforce stranger awareness
A, B, C, E
A nurse is planning diversionary activities for school-age children on an inpatient pediatric unit. Which of the following activities should the nurse include? Select all that apply. a. Building models b. Playing video games c. Reading books d. Using toy carpentry tools e. Playing board games
A, B, C, E
A nurse is caring for a group of clients on a medical-surgical unit. For which of the following client care needs should the nurse initiate a referral for a social worker? a. A client who has terminal cancer requests hospice care in her home b. A client asks about community resources available for older adults c. A client states that she wants her child baptized before surgery d. A client requests an electric wheelchair for use after discharge e. A client states that he does not understand how to use a nebulizer
A, B, D
A nurse is discussing occurrences that require completion of an incident report with a newly license nurse. Which of the following should the nurse include in the teaching? Select all that apply. a. Medication error b. Needlesticks c. Conflict with provider and nursing staff d. Omission of prescription e. Complaint from a client's family member
A, B, D
A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? Select all that apply. a. Home health care b. Rehabilitation facilities c. Diagnostic centers d. Skilled nursing facilities d. Oncology centers
A, B, D
A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? Select all that apply. a. Request assistance when repositioning a client b. Avoid twisting your spine or bending at the waist c. Keep you knees slightly lower than your hip when sitting for long periods of time d. Use smooth movements when lifting and moving clients e. Take a break from repetitive movements every 2 to 3 hr to flex and stretch your joints and muscles
A, B, D
A nurse is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? Select all that apply. a. Restlessness b. Tachypnea c. Bradycardia d. Confusion e. Pallor
A, B, D, E
A nurse is caring for a client who had a stroke and is scheduled for transfer to a rehabilitation center. Which of the following tasks are the responsibility of the nurse at the transferring facility? Select all that apply. a. Ensure that the client has possession of his valuables b. Confirm that the rehabilitation center has a room available at the time of transfer c. Assess how the client tolerates the transfer d. Give a verbal report via telephone e. Complete a transfer form for the receiving facility
A, B, D, E
A nurse is talking with a client about ways to help him sleep and rest. Which of the following recommendations should the nurse give to the client to promote sleep and rest? Select all that apply. a. Practice muscle relaxation techniques b. Exercise each morning c. Take an afternoon nap d. Alter the sleep environment for comfort e. Limit fluid intake at least 2 hr before bedtime
A, B, D, E
A nurse educator is reviewing a newly hired nurse the difference in manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states which of the following are manifestations of a systemic infection? Select all that apply. a. Fever b. Malaise c. Edema d. Pain or tenderness e. Increase in pulse and respiratory rate
A, B, E
A nurse educator is teaching a module about safe medication administration to newly licensed nurses. Which of the following statements should the nurse identify as an indication that one of the group understands how to implement medication therapy? Select all that apply. a. "I will observe for side effects." b. "I will monitor for therapeutic effects." c. "I will prescribe the appropriate dose." d. "I will change the dose if adverse effects occur." e. "I will refuse to give a medication if I believe it is unsafe."
A, B, E
A nurse is determining a client's ability to learn self-monitoring of blood glucose using a glucometer. Which of the following abilities should the nurse confirm that the client has before proceeding with instruction? Select all that apply. a. Finger dexterity b. Visual acuity c. Color vision d. Basic literacy e. Demonstration ability
A, B, E
A nurse is instructing a client who has diabetes mellitus 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 over-the-counter products to treat abrasions e. Wear cotton socks
A, B, E
A nurse is reviewing a client's medication history. The client has an admission blood glucose of 260 mg/dL and no documented history of diabetes mellitus. Which of the following types of medication should alert the nurse to the possibility that the client has developed an adverse effect of pharmacological therapy. Select all that apply. a. Diuretics b. Corticosteroids c. Oral anticoagulants d. Opiod analgesics e. Antipsychotics
A, B, E
A nurse is teaching a client who has a new prescription for oxybutynin about managing the medication's anti-cholinergic effects. Which of the following instructions should the nurse include? Select all that apply. a. Take sips of water frequently b. Wear sunglasses when outdoors in sunlight c. Use a soft toothbrush when brushing teeth d. Take the mediction with an antacid e. Urinate prior to taking the medicatoin
A, B, E
What techniques encourage a client to tell his or her full story? (Select all that apply.) A) Active listening B) Back channeling C) Use of open-ended questions D) Use of closed-ended questions
A, B, and C Options 1, 2, and 3 encourage clients to tell their full stories. Closed-ended questions allow clients to answer with one or two words, which makes it more difficult to obtain all the information required for a full story. The other options give clients the opportunity to tell their stories and feel supported. Active listening helps them feel that they, and their stories, are important.
Which of the following are nurse-provided indirect care activities? (Select all that apply.) A) Delegating B) Documenting C) Evaluating new products D) Administering medications E) Providing client counseling
A, B, and C The correct options do not involve direct interaction with the client or family. The other options do require such direct interaction.
The nurse gathered the following assessment data. Which of these cues form a pattern? (Select all that apply.) A) Client is restless. B) Respirations are 24/min and irregular. C) Client states feeling short of breath. D) Fluid intake for 8 hours is 800 ml. E) Client has drainage from surgical wound. F) Client reports loss of appetite for over 2 weeks.
A, B, and C The data in items 1, 2, and 3—rapid irregular breathing, complaints of shortness of breath, and restlessness—form a pattern indicating that the client may be experiencing hypoxia, because all are signs and symptoms characteristic of this condition. The other information, although important, is not related to hypoxia.
Which of the following are defining characteristics for the nursing diagnosis of Impaired urinary elimination? (Select all that apply.) A) Nocturia B) Frequency C) Urinary retention D) Inadequate urinary output E) Receipt of intravenous fluids F) Sensation of bladder fullness
A, B, and C The defining characteristics for Impaired urinary elimination according to NANDA include nocturia, frequency, and urinary retention. The other options are not defining characteristics from NANDA.
A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication he is receiving for pain management. Which of the following members of the interprofessional care team can assist the client in understanding the medication's effects? Select all that apply a. Provider b. Certified nursing assistant c. Pharmacist d. Registered Nurse e. Respiratory Therapist
A, C, D
A nurse is giving a presentation about accident prevention to a group of parents of toddlers. Which of the following accident-prevention strategies should the nurse include? Select all that apply. a. Store toxic agents in locked cabinets b. Keep toilet seats up c. Turn pot handles toward the back of the stove d. Place safety gates across stairways e. Make sure balloons are fully inflated
A, C, D
A nurse is reaching a group of nursing students 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 the students to use? Select all that apply. a. Guided Imagery b. Massage therapy c. Meditation d. Music therapy e. Therapeutic touch
A, C, D
A nurse is reviewing CDC immunization recommendations with a young adult client. Which of the following vaccines should the nurse recommend as routine rather than catch-up, during young adulthood? Select all that apply. a. Influenza b. Measles, mumps, rubella c. Pertussis d. Tetanus e. Polio
A, C, D
A nurse is reviewing the laboratory test results for a client who has an elevated temperature. The nurse should recognize which of the following findings is a manifestation of dehydration? Select all that apply. a. Hct 55% b. Serum osmolarity 260 mOsm/kg c. Serum sodium 150 mEq/L d. Urine specific gravity 1.035 e. Serum creatinine 0.6 mg/dL
A, C, D
A nurse in a provider's office is caring for a client who states that, for the past week, she has felt tired during the day and cannot sleep at night. Which of the following responses should the nurse ask when collected data about the client's difficulty sleeping? Select all that apply. a. "Does your lack of sleep interfere with your ability to function during the day?" b. "Do you feel confused in the late afternoon?" c. "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?" d. "Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep?" e. "Tell me about any personal stress you are experiencing."
A, C, D, E
A nurse is planning diversionary activities for preschoolers on an inpatient pediatric unit. Which of the following activities should the nurse include? Select all that apply. a. Assembling puzzles b. Pulling wheeled toys c. Using musical toys d. Playing with puppets e. Coloring with crayons
A, C, D, E
A nurse is preparing a health promotion course for a group of middle adults. Which of the following strategies should the nurse recommend? Select all that apply. a. Eye examination every 1 to 3 years b. Decrease intake of calcium supplements c. DXA screening for osteoporosis d. Increase intake of carbohydrate in the diet e. Screening for depressive disorders
A, C, D, E
A nurse is talking with an older adult client about improving her nutritional status. Which of the following interventions should the nurse recommend? Select all that apply. a. Increase protein intake to increase muscle mass b. Decrease fluid intake to prevent urinary incontinence c. Increase calcium intake to prevent osteoporosis d. Limit sodium intake to prevent edema e. Increase fiber intake to prevent constipation
A, C, D, E
A nurse on a pediatric unit is caring for an adolescent who has multiple fractures. Which of the following interventions should the nurse take? Select all that apply. a. Suggest that his parents bring in video games for him to play b. Provide a television and DVDs for the adolescent to watch c. Limit visitors to the adolescent's immediate family d. Involve the adolescent in treatment decisions when possible e. Allow the adolescent to perform his own morning care
A, C, D, E
A nurse in a residential care facility is assessing an older adult client. Which of the following findings should the nurse identify as atypical indications of infection? Select all that apply. a. Urinary incontinence b. Malaise c. Acute confusion d. Fever e. Agitation
A, C, E
A nurse is collecting history and physical examination data from a middle adult. The nurse should expect to find decreases in which of the following physiologic functions? Select all that apply. a. Metabolism b. Ability to hear low-pitched sounds c. Gastric secretions d. Far vision e. Glomerular filtration
A, C, E
A nurse is preparing a presentation at a local community center about sleep hygiene. When explaining rapid eye movement (REM) sleep, which of the following characteristics should the nurse include? Select all that apply. a. REM sleep provides cognitive restoration b. REM sleep lasts about 90 min c. It is difficult to awaken a person in REM sleep d. Sleepwalking occurs during REM sleep e. Vivid dreams are common during REM sleep
A, C, E
A nurse is reviewing complementary and alternative therapies with a group of nursing students. The nurse should classify which of the following interventions as mind-body therapy? Select all that apply. A. Art therapy b. Acupressure c. Yoga d. Therapeutic touch e. Biofeedback
A, C, E
Which of the following actions should the nurse take when using the communication technique of active listening? Select all that apply. a. Use an open posture b. Write down what the client says to avoid forgetting details c. Establish and maintain eye contact d. Nod in agreement with the client throughout the conversation e. Respond positively when giving feedback
A, C, E
When determining a client's ability to perform instrumental activities of daily living, which of the following skills does the nurse assess? (Select all that apply.) A) Ability to cook meals B) Ability to feed oneself C) Ability to write checks D) Ability to bathe oneself E) Ability to take medications
A, C, and E The correct options are skills that allow the client to live independently in society. They may or may not be performed on a daily basis. The other options are activities of daily living.
A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in his surgical incision. The nurse checks the surgical wound and finds it separate with viscera protruding. Which of the following actions should the nurse take? Select all that apply. a. Cover the area with saline-soaked sterile dressings b. Apply an abdominal binder snugly around the abdomen c. Use sterile gauze to apply gentle pressure to the exposed tissues d. Position the client supine with his hips and knees bent e. Offer the client a warm beverage, such as herbal tea
A, D
A nurse is caring for a client who reports difficulty hearing. Which of the following assessment findings indicate a sensorineural hearing loss in the left ear? Select all that apply. a. Weber test showing lateralization to the right ear b. Light reflex at 10 o' clock in the left ear c. Indication of obstruction in the left ear d. Rinne test showing less time for air and bone conduction e. Rinne test showing air conduction less than bone conduction
A, D
A nurse is preparing to administer a 0900 medication to a client. Which of the following are acceptable administration times for this medication? Select all that apply. a. 0905 b. 0825 c. 1000 d. 0840 e. 0935
A, D
A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? Select all that apply. a. Respiratory rate is 22/min with even, unlabored respirations b. The client's partner states, "He said he hurts after walking about 10 minutes c. Pain rating is 3 on a scale of 0 to 10 D. Skin is pink, warm, and dry E. The assistive personnel reports the client walked with a limp
A, D, E
A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? Select all that apply. a. Capillary refill less than 2 seconds b. 1+ pitting edema in both feet c. Pale nail beds in both hands d. Thick skin on the soles of the feet e. Numerous light brown macules on the face
A, D, E
A nurse in a provider's office is preparing to perform a breast examination for an older adult client who is postmenopausal. Which of the following findings should the nurse expect? Select all that apply. a. Smaller nipples b. Less adipose tissue c. Nipple discharge d. More pendulous e. Nipple inversion
A, D, E
A nurse is assessing a 2-week-old newborn during a checkup. Which of the following findings should the nurse expect? Select all that apply. a. Sleeps 14 to 16 hr each day b. Posterior fontanel closed c. Pincer grasp present d. Hands remain in a closed position e. Current weight same as birth weight
A, D, E
A nurse is assessing a client's thyroid gland as part of a comprehensive physical examination. Which of the following findings should the nurse expect? Select all that apply. a. Palpating the thyroid in the lower half of the neck b. Visualizing the thyroid on inspection of the neck c. Hearing a bruit when auscultating the thyroid d. Feeling the thyroid ascend as the client swallows e. Finding symmetric extensions off the trachea on both sides of the midline
A, D, E
A nurse is consoling the partner of a client who just expired after a long battle with liver cancer. The partner is displaying grief and states, "I hate him for leaving me." Which of the following statements by the nurse successfully facilitates mourning for the grieving partner? Select all that apply. a. "Would you like me to contact the chaplain to come 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 is quite normal to feel anger toward your husband at this time." e. "Tell me more about how you are feeling."
A, D, E
A nurse is preparing to perform endotracheal suctioning for a client. The nurse should follow which of the following guidelines? Select all that apply. a. Apply suction while withdrawing the catheter b. Perform suctioning on a routine basis, every 2 to 3 hr c. Maintain medical asepsis during suctioning d. Use a new catheter for each suctioning attempt e. Limit total suctioning time to 5 minutes
A, D, E
A nurse is reviewing factors that increase the risk of urinary tract infections (UTIs) with a client who has recurrent UTIs. Which of the following factors should the nurse include? Select all that apply. a. Frequent sexual intercourse b. Lowering of testosterone levels c. Wiping from front to back d. Location of the urethra in relation to the anus e. Frequent catheterization
A, D, E
A nurse on the IV team is conduction an in-service education program about the complications of IV therapy. Which of the statements by an attendee indicates an understanding of the manifestations of infiltration? Select all that apply. a. "The temperature around the IV site is cooler." b. "The rate of the infusion increases." c. "The skin at the IV site is red." d. "The IV dressing is damp." e. "The tissue around the venipuncture site is swollen."
A, D, E
A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? Select all that apply. a. Stage III pressure ulcer b. Sutured surgical incision c. Casted bone fracture d. Laceration sealed with adhesive e. Open burn area
A, E
Which of the following behaviors by the nurse demonstrates that the nurse is participating in critical thinking? Select all that apply. A. Admitting not knowing how to do a procedure and requesting help B. Using clever and persuasive remarks to support an opinion or position C. Accepting without question the values acquired in nursing school D. Finding a quick and logical answer, even to complex questions E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs 300 lbs.
A. Admitting not knowing how to do a procedure and requesting help E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs 300 lbs. Rationale: Critical thinking in nursing is self-directed, supporting what nurses know and making clear what they do not know. It is important for nurses to recognize when they lack the knowledge they need to provide safe care for a client (option 1). Nurses must also utilize their resources to acquire the support they need to care for a client safely (option 5). Options 2, 3, and 4 do not demonstrate critical thinking.
The nurse assigned to care for a postoperative client has asked an unlicensed assistive person (UAP) to help the client ambulate in the hall. Before delegating this task, the nurse must do which of the following? A. Assess the client to be sure ambulation with assistance is an appropriate care measure B. Ask the client if he or she is ready to ambulate C. Ask whether the UAP has time to assist the client D. Ask the charge nurse whether UAPs have ambulated the client during this shift
A. Assess the client to be sure ambulation with assistance is an appropriate care measure Rationale: Prior to delegating any client care responsibilities, the nurse must assess the client to assure that the delegation is appropriate to his or her care. Options 2, 3, and 4 would not constitute an assessment of the client's current status.
The nurse anticipates that a right-handed client with a fractured right arm will require assistance with activities of daily living. What skill is the nurse demonstrating? A) Cognitive skill B) Behavioral skill C) Interpersonal skill D) Psychomotor skill
A. Cognitive skill The nurse is using sound judgment and clinical decisions to provide individualization of care. A decision is made without direct interaction with the client but is based on knowledge about the client. No psychomotor skill is involved in this decision-making process. There is no such thing as a behavioral skill.
When evaluating an elderly client's blood pressure (BP) of 146/78 mmHg, the nurse does which of the following before determining whether the BP is normal or represents hypertension? A. Compare this reading against defined standards B. Compare the reading with one taken in the opposite arm C. Determine gaps in the vital signs in the client record D. Compare the current measurement with previous ones
A. Compare this reading against defined Rationale: Analysis of the client's BP requires knowledge of the normal BP range for an older adult. The nurse compares the client's data against identified standards to determine whether this reading is normal or abnormal. Measuring the BP in the other arm (option 2) and comparing the reading to previous ones (option 4) will give additional client data, but the comparison alone will not determine whether the BP is normal. Gaps in the record (option 3) will not aid in interpreting the current measurement.
A nurse is caring for a client who has a history of falls. Which of the following is the nurse's priority? A. Complete a fall-risk assessment B. Educate the client and family about fall risks C. Eliminate safety hazards from the client's environment D. Make sure the client uses assistive aids in his possession
A. Complete a fall-risk assessment
The assessment phase of the teaching process includes: A) Determining learning needs B) Setting priorities C) Selecting teaching methods D) Selecting teaching approach
A. Determining learning needs Information obtained during the assessment will determine what is necessary for the client to learn. Because the health status of the client may undergo changes, assessment for learning needs is an ongoing process. Setting priorities and selecting teaching methods are part of the planning phase. Selection of the teaching approach is part of the implementation phase.
A client tells the nurse, "I'm not happy with the way the patient care technician did my bath. He just seemed to be in a hurry and did not wash my back like I asked." The nurse decides to go talk with the technician to learn his side of the story as well. This is an example of: A. Fairness B. Curiosity C. Risk taking D. Responsibility
A. Fairness Fairness involves analyzing all viewpoints to understand the situation completely before making a decision. Curiosity gives the critical thinker the motivation to continue to ask questions and learn more. Risk taking involves trying different ways to solve problems.
The nursing assessment is which phase of the nursing process? A) First B) Second C) Third D) Fourth
A. First The nursing process cannot proceed unless the nurse first conducts a client assessment. The other phases of the nursing process occur after assessment.
Theories that are broad and complex are: A) Grand theories B) Descriptive theories C) Middle-range theories D) Prescriptive theories
A. Grand theories Grand theories are described as broad and complex. Middle-range theories are limited in scope, less abstract, address specific phenomena or concepts, and reflect practice. Descriptive theories describe phenomena, speculate as to why the phenomena occur, and describe the consequences of phenomena. Prescriptive theories address nursing interventions and predict the consequence of a specific intervention.
The nurse prepares a client for a lumbar puncture. Before the start of the procedure the nurse is sure to: A) Have the client void. B) Place the client in Sims' position. C) Premedicate the client with analgesics. D) Insert a peripheral intravenous (IV) catheter.
A. Have the client void The nurse takes care of physical needs (voiding) that could interrupt the procedure and possibly increase the risk of complications. The client assumes the fetal position or sits upright with arms over a bedside table. Because lidocaine is used in lumbar puncture, analgesics are not essential. Peripheral IV catheters are not required for this procedure.
The nurse asks the client whether the client has any allergies. This is an example of: A) Health history data B) Biographical information C) History of present illness D) Environmental history data
A. Health history data Known allergies are a part of historical data. Biographical data include age, address, occupation, work status, marital status, course of health care, and insurance. The history of the present illness includes when the symptoms began, whether they began suddenly or gradually, whether they come and go, and other information about the illness. The environmental history includes data about the client's home and working environments.
nurse routinely asks clients if they take any vitamins or herbal medications, encourages family members to bring in music that clients like to help them relax, and frequently prays with clients if that is important to them. The nurse is using which model of care? A) Holistic B) Health belief C) Transtheoretical D) Health promotion
A. Holistic The holistic model attempts to create conditions that promote optimal health. The holistic model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions. The health belief model addresses the relationship between a person's beliefs and behaviors. The transtheoretical model of change discusses a series of changes through which clients move, starting with precontemplation and ending maintenance. The health promotion model defines health as a positive, dynamic state and not merely the absence of disease.
A postsurgical client calls for a nurse and asks to be repositioned. The nurse finds that the client's drainage tube is disconnected and the intravenous (IV) line has 100 ml of fluid remaining. Which of the following should be performed first? A) Reconnect the drainage tube. B) Inspect the condition of the IV dressing. C) Improve the client's comfort and turn her to her side. D) Go to the medication room and obtain the next IV fluid bag.
A. Reconnect the drainage tube The nurse should reconnect the drainage tube first to ensure that the wound is properly draining. The client should then be turned (with care taken to ensure that the tubing remains connected), followed by replacing the IV fluid bag, checking the IV site, and restarting the IV fluid. With 100 ml left, the nurse has a bit of time to replace the IV bag before it runs dry, so caring for the client's wound and comfort should come first.
A nurse manager is reviewing guidelines to prevent injury with staff nurses. Which of the following should the nurse manager include in the teaching? SELECT ALL THAT APPLY A. Request assistance when repositioning a client. B. Avoid twisting the spine or bending at the waist. C. Keep the knees slightly lower than the hips when sitting for long periods of time. D. Use smooth movements when lifting and moving clients. E. Take a break from repetitive movements every 2 to 3 hr to flex and stretch joints and muscles.
A. Request assistance when repositioning a client. B. Avoid twisting the spine or bending at the waist. D. Use smooth movements when lifting and moving clients.
The client states, "My chest hurts and my left arm feels numb." The nurse interprets that this data is of which type and source? A. Subjective data from a primary source B. Subjective data from a secondary source C. Objective data from a primary source D. Objective data from a secondary source
A. Subjective data from a primary source Rationale: The client states, "My chest hurts and my left arm feels numb." The nurse interprets that this data is of which type and source?
Which activity would be appropriate for the nurse to delegate to an unlicensed assistive person (UAP)? A. Taking vital signs of clients on the nursing unit B. Assisting the physician with an invasive procedure C. Adjusting the rate on an infusion pump D. Evaluating achievement of client outcome goals
A. Taking vital signs of clients on the nursing unit Rationale: Part of the professional nurse's role is to delegate responsibility for activities while maintaining accountability. The nurse must match the needs of the client with the skills and knowledge of UAPs. Certain skills and activities, such as those in options 2, 3, and 4, are not within the legal scope of practice for a UAP.
A client who is having chest pain is to undergo emergency cardiac catheterization. Which of the following is the most appropriate teaching approach in this situation? A) Telling approach B) Entrusting approach C) Reinforcing approach D) Participating approach
A. Telling approach The telling approach is used when teaching limited information, such as in an emergent situation. The entrusting approach provides the client the opportunity to manage self-care. In the participating approach, the nurse and client set objectives and become involved in the learning process together. Reinforcement requires the delivery of a stimulus that increases the probability of a response.
A 72-year-old man diagnosed with chronic obstructive pulmonary disease 5 years ago has been participating for the last 2 years in a pulmonary rehabilitation exercise class offered by the local hospital at a fitness facility. This is what level of prevention? A) Tertiary prevention B) Primary prevention C) Secondary prevention D) Quaternary prevention
A. Tertiary prevention Tertiary prevention occurs when a defect or disability is permanent and irreversible, and the aim is to reduce negative impacts and complications. Primary prevention is true prevention that precedes disease and involves clients considered physically and emotionally healthy. Secondary prevention is aimed at individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Quaternary prevention is not a recognized term.
A client was in pain following surgery. The nurse administered the prescribed analgesics, but the client's pain rating stayed the same (8 out of 10). What should the nurse recognize? A) The pain plan needs changing. B) The client is overrating the pain. C) Complications from surgery are occurring. D) Nonpharmacological pain-relieving strategies are now appropriate.
A. The pain plan needs changing The current pain medications are not effectively relieving the pain. The nurse needs to call the physician and discuss changing the medication is some way (type, dose, frequency, formulation). Pain is what the client says it is. There is no objective way to measure pain. The clinician must accept the client's report of pain. Nonpharmacological strategies are adjuncts to the pain plan. They are not to be used in place of pain medications. Pain following surgery is an expectation.
Nursing theories focus on the phenomena of nursing and nursing care. Which of the following is true of phenomena? A) They are aspects of reality that can be consciously sensed or experienced. B) They convey the general meaning of concepts in a manner that fits the theory. C) They are statements that describe concepts or connect two concepts that are factual. D) They are mental formulations of an object or event that come from individual perceptual experience.
A. They are aspects of reality that can be consciously sensed or experienced. Phenomena are defined as aspects of reality that can be consciously sensed or experienced.
The nurse asks a client, "Ms. Neil, describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?" This series of questions would likely occur during which phase of a client interview? A) Working B) Orientation C) Termination
A. Working The nurse's questions exemplify the working phase of the interview.
Private Law?
AKA: Civil law. Most law associated with nursing. -Regulates relationships among people.
67.The charge nurse assigns a nursing procedure to a new staff nurse who has not previously performed the procedure. What action is most important for the new staff nurse to take? A. Review the steps in the procedure manual. B. Ask another nurse to assist while implementing the procedure. C. Follow the agency's policy and procedure. D. Refuse to perform the task that is beyond the nurse's experience.
According to states' nurse practice acts, it is the responsibility of the nurse to function within the scope of competency (D), and in this case safe nursing practice constitutes refusal to perform the procedure because of a lack of experience. Although state mandates, agency policies, and continued education and experience identify tasks that are within the scope of nursing practice, nurses should first refuse to perform tasks that are beyond their proficiency, and then pursue opportunities to enhance their competency (A, B, and C). Correct Answer: D
5.A nurse is becoming increasingly frustrated by the family members' efforts to participate in the care of a hospitalized client. What action should the nurse implement to cope with these feelings of frustration? A. Suggest that other cultural practices be substituted by the family members. B. Examine one's own culturally based values, beliefs, attitudes, and practices. C. Explain to the family that multiple visitors are exhausting to the client. D. Allow the situation to continue until a family member's action may harm the client.
Acknowledging a client's beliefs and customs related to sickness and health care are valuable components in the plan of care that prevents conflict between the goals of nursing and the client's cultural practices. Cultural sensitivity begins with examining one's own cultural values (B) to compare, recognize, and acknowledge cultural bias. (A and C) do not consider the family's needs to care for the client and are not the best ways to cope with the nurse's frustration. Although (D) may be an option, examining one's cultural differences allows the nurse to cope, empathize, and implement culturally specific interventions pertaining to the needs of the client and the family. Correct Answer: B
During a physical assessment, a female client begins to cry. Which action is best for the nurse to take? A. Request another nurse to complete the physical assessment. B. Ask the client to stop crying and tell the nurse what is wrong. C. Acknowledge the client's distress and tell her it is all right to cry. D. Leave the room so that the client can be alone to cry in private.
Acknowledging the client's distress and giving the client the opportunity to verbalize her distress (C) is a supportive response. (A, B, and D) are not supportive and do not facilitate the client's expression of feelings. Correct Answer: C
Integrity =
Acting according to code of ethics and standards of practice
91.The nurse is caring for a client who is weak from inactivity because of a 2-week hospitalization. In planning care for the client, the nurse should include which range of motion (ROM) exercises? A. Passive ROM exercises to all joints on all extremities four times a day. B. Active ROM exercises to both arms and legs two or three times a day. C. Active ROM exercises with weights twice a day with 20 repetitions each. D. Passive ROM exercises to the point of resistance and slightly beyond.
Active, rather than passive, ROM is best to restore strength and (B) is an effective schedule. Passive ROM 4 times a day (A) is not as beneficial for the client as (B). With weights (C), the client may fatigue quickly and develop muscle soreness. ROM is not performed beyond the point of resistance or pain (D) because of the risk of damage to underlying structures. Correct Answer: B
The nurse identified that the patient has pain on a scale of 7, he winces during movement, and he expresses discomfort over the incisional area. He guards the area by resisting movement. The incision appears to be healing, but there is natural swelling. Write a three-part nursing diagnostic statement using the PES format. [17]
Acute pain r/t incisional trauma evidenced by pain reported at 7, with guarding, and restricted turning and positioning.
40.When teaching a female client to perform intermittent self-catheterization, the nurse should ensure the client's ability to perform which action? A. Locate the perineum. B. Transfer to a commode. C. Attach the catheter to a drainage bag. D. Manipulate a syringe to inflate the balloon.
Adequate visualization or palpation of the perineum (A) is essential to ensure correct placement of the catheter. (B) is not necessary to perform self-catheterization. During a self-catheterization, the client typically allows the urine to drain into an open collection device, rather than a drainage bag (C), and uses a straight catheter without a balloon (D). Correct Answer: A
18.A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What action should the nurse implement? A. Document the client's request in the medical record. B. Ask the client if this decision has been discussed with his healthcare provider. C. Inform the client that a written, notarized advance directive, is required to withhold resuscitation efforts. D. Advise the client to designate a person to make healthcare decisions when the client is unable to do so.
Advance directives are written statements of a person's wishes regarding medical care, and verbal directives may be given to a healthcare provider with specific instructions in the presence of two witnesses. To obtain this prescription, the client should discuss his choice with the healthcare provider (B). (A) is insufficient to implement the client's request without legal consequences. Although (C and D) provide legal protection of the client's wishes, the present request needs additional action. Correct Answer: B
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take?
After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement? A. Obtain the pre-transfusion hemoglobin level. B. Prime the tubing and prepare a blood pump set-up. C. Monitor vital signs q15 minutes for the first hour. D. Ensure the accuracy of the blood type match.
All interventions should be implemented prior to administering blood, but (D) has the highest priority. Any time blood is administered, the nurse should ensure the accuracy of the blood type match in order to prevent a possible hemolytic reaction. Correct Answer: D
used to treat ventricular fibrillation and unstable ventricular tachycardia
Amiodarone
41.A client in hospice care develops audible gurgling sounds on inspiration. Which nursing action has the highest priority? A. Ensure cultural customs are observed. B. Increase oxygen flow to 4L/minute. C. Auscultate bilateral lung fields. D. Inform the family that death is imminent.
An audible gurgling sound produced by a dying client is characteristic of ineffective clearance of secretions from the lungs or upper airways, causing a rattling sound as air moves through the accumulated fluid. The nursing priority in this situation is to convey to the family that the client's death is imminent (D). Although culturally sensitive care should be observed throughout the client's plan of care (A), this is not the priority at this time. Administration of oxygen may be expected care, but a flow rate greater than 2 L/minute (B) is not palliative care. (C) may provide additional information, but is not necessary as death approaches. Correct Answer: D
9.Which statement correctly identifies a written learning objective for a client with peripheral vascular disease? A. The nurse will provide client instruction for daily foot care. B. The client will demonstrate proper trimming toenail technique. C. Upon discharge, the client will list three ways to protect the feet from injury. D. After instruction, the nurse will ensure the client understands foot care rationale.
An objective should contain four elements: who will perform the activity or acquire the desired behavior, the actual behavior that the learner will exhibit, the condition under which the behavior is to be demonstrated, and the specific criteria to be used to measure success. (C) is a concise statement that is a learning objective that defines exactly how the client will demonstrate mastery of the content. (A, B, and D) lack one or more of these elements. Correct Answer: C
A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first? A. Assist the ambulating client back to the bed. B. Encourage the client to ambulate to resolve pneumonia. C. Obtain a prescription for portable oxygen while ambulating. D. Move the oximetry probe from the finger to the earlobe.
An oxygen saturation below 90% indicates inadequate oxygenation. First, the client should be assisted to return to bed (A) to minimize oxygen demands. Ambulation increases aeration of the lungs to prevent pooling of respiratory secretions, but the client's activity at this time is depleting oxygen saturation of the blood, so (B) is contraindicated. Increased activity increases respiratory effort, and oxygen may be necessary to continue ambulation (C), but first the client should return to bed to rest. Oxygen saturation levels at different sites should be evaluated after the client returns to bed (D). Correct Answer: A
61.The daughter of an older woman who became depressed following the death of her husband asks, "My mother was always well-adjusted until my father died. Will she tend to be sick from now on?" Which response is best for the nurse to provide? A. She is almost sure to be less able to adapt than before. B. It's highly likely that she will recover and return to her pre-illness state. C. If you can interest her in something besides religion, it will help her stay well. D. Cultural strains contribute to each woman's tendencies for recurrences of depression.
Analysis of behavior patterns using Erikson's framework can identify age-appropriate or arrested development of normal interpersonal skills. Erikson describes the successful resolution of a developmental crisis in the later years (older than 65-years) to include the achievement of a sense of integrity and fulfillment, wisdom, and a willingness to face one's own mortality and accept the death of others (B). Depression is a component of normal grieving, and (A) does not represent susceptible adaptation to the developmental crisis of an older adult, Integrity vs despair. (C and D) are judgmental and not therapeutic. Correct Answer: B
Which of the following clients meets the criteria for selection of apical site for assessment of the pulse rather than radial pulse? A. A client is in shock B. The pulse changes with body position changes C. A client with an arrhythmia D. It is less than 24 hours since a client's surgical operation
Answer: C. A client with an arrhythmia Rationale: the apical pulse would confirm the rate and determine the actual cardiac rhythm for a client with an abnormal rhythm.
While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? a. acknowledge that she is supporting the arm correctly b. encourage her to keep the joint covered to maintain warmth c. reinforce the need to grip directly under the joint for better support d. instruct her to grip directly over the joint for better motion
Answer: a. acknowledge that she is supporting the arm correctly Rationale: the wife is performing the passive ROM correctly, therefore the nurse should acknowledge this fact (a). The joint being exercised should be uncovered (b) while the rest of the body should remain covered for warmth and privacy. (c and d) do not provide adequate support to the joint while still allowing for joint movement.
A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first? a. assist the ambulating client back to the bed b. encourage the client to ambulate to resolve pneumonia c. obtain a prescription for portable oxygen while ambulating d. move the oximetry from the finger to the earlobe
Answer: a. assist the ambulating client back to bed Rationale: an oxygen saturation below 90% indicates inadequate oxygenation. First the client should be assisted to return to bed (a) to minimize oxygen demands. Ambulation increases aeration of the lungs to prevent pooling of respiratory secretions, but the client's activity at this time is depleting oxygen saturation of the blood so (b) is contraindicated. Increased activity increases respiratory effort, and oxygen may be necessary to continue ambulation (c) but first the client should return to bed to rest. Oxygen saturation levels at different sites should be evaluated after the client returns to bed (d).
The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in the teaching plan? a. avoid any types of sprays, powders, or perfumes b. wearing a mask while cleaning will not help to avoid allergens c. purchase any type of clothing, but be sure it is washed before wearing it d. pollen count is related to hay fever, not to allergies
Answer: a. avoid any types of sprays, powders, or perfumes Rationale: the client with allergies should be instructed to reduce any exposure to pollen, dust, fumes, odors, sprays, powders, and perfumes (a). The client should be encouraged to wear a mask when working around dust or pollen (b). Clients with allergies should avoid any clothing that causes itching; washing clothes will not prevent an allergic reaction to some fabrics (c). Pollen count is related to allergens (d) and the client should be instructed to stay indoors when pollen count is high.
An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? a. be sure to have a complete physical assessment before beginning your planned exercise program b. be careful that the exercise program doesn't simply add to your stress level, making you want to eat more c. increased exercise helps to reduce stress, so you may not need to spend money on a stress management class d. make sure to monitor your weight loss regularly to provide a sense of accomplishment and motviation
Answer: a. be sure to have a complete physical examination before beginning your planned exercise program Rationale: the most important teaching is (a) so that the client will not begin a dangerous level of exercise he is not sufficiently fit for. This might result in chest pain, heart attack, or a stroke. (b,c,d) are important instructions but less priority than (a).
Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutrition? a. chocolate pudding b. graham crackers c. sugar free gelatin d. apple slices
Answer: a. chocolate pudding Rationale: the client with myasthenia gravis is at high risk for altered nutrition because of fatigue and muscle weakness resulting in dysphagia. Snacks that are semisolid like pudding (a) are easy to swallow and require minimal chewing effort, and provide calories and protein. (c) does not provide any nutritional value. (b ad d) require energy to chew and are more difficult to swallow than pudding.
The nurse plans to obtain health assessment information from a primary source. Which option is a primary source for the completion of the health assessment? a. client b. healthcare provider c. a family member d. previous medical records
Answer: a. client Rationale: a primary source of information for a health assessment in the client (a). (b,c,d) are considered secondary sources about the client's health history, but other details such as subjective data, can only be provided directly from the client
A client with chronic kidney disease selects a scrambled egg for his breakfast. What action should the nurse take? a. commend the client for selecting a high biologic value protein b. remind the client that protein in the diet should be avoided c. suggest that the client also select orange juice, to promote absorption d. encourage the client to attend classes on dietary management of CKD
Answer: a. commend the client for selecting a high biologic value protein Rationale: Foods such as milk and eggs (a) are high biologic proteins which are allowed because they are complete proteins and supply essential amino acids that are necessary for growth and cell repair. Although a low-potassium diet is followed (b) some protein is essential. Orange juice is rich in potassium and should not be encouraged (c). The client has made a good diet choice so d is not necessary.
After completing an assessment and determining that a client has a problem, which action should the nurse perform next? a. determine the etiology of the problem b. prioritize nursing care interventions c. plan appropriate interventions d. collaborate w/ the client to set goals
Answer: a. determine the etiology of the problem Rationale: before planning care, the nurse should determine the etiology/cause of the problem (a) because this will help determine (b,c,d).
While obtaining a health history the nurse asks Mr. Jones if he has noted any changes in his activity tolerance. This is an example of which interview technique? a. direct question b. problem solving c. problem seeking d. open ended question
Answer: a. direct question Rationale: some may be focused, and others may be comprehensive
The nurse is using a genogram while conducting a client's health assessment and past medical history. What information should the genogram provide? a. genetic and familial health disorders b. chronic health problems c. reason for seeking health care d. undetected disorders
Answer: a. genetic and familial health disorders Rationale: A genogram is used during the health assessment process identifies genetic and familial health disorders (a). It may not identify the client's chronic health problems (b) so it is not a reason to seek health care (c). A genogram is not a diagnostic tool to detect disorders (d) such as those based on pathological findings or DNA
A client who is in hospice care complains of increasing amounts of pain. The health care provider prescribes an analgesic every 4 hours as needed. Which action should the nurse implement? a. give an around the clock schedule for administration of analgesics b. administer analgesic medication as needed when the pain is severe c. provide medication to keep the client sedated and unaware of stimuli d. offer a medication-free period so that the client can do daily activities
Answer: a. give an around the clock schedule for administration of analgesics. Rationale: the most effective pain management is achieved using ATC schedule that provides analgesic medications on a regular basis (a) and in a timely manner. Analgesics are less effective if pain persists until it is severe, so an analgesic medication should be administered before the client's pain peaks (b). Providing comfort is a priority for the client who is dying, but sedation that impairs the client's ability to interact and experience the time before life ends should be minimized (c). Offering a medication-free period allows the serum drug level to fall, which is not an effective method to manage chronic pain (d).
An African American grandmother tells the nurse that her 4 year old grandson is suffering from the "miseries". Based on this statement which focused assessment should the nurse conduct? a. inquire about the source and type of pain b. examine the nose for congestion and discharge c. take vital signs for temperature elevation d. explore the abdominal area for distention
Answer: a. inquire about the source and type of pain Rationale: different cultural groups often have their own terms for health conditions. African-American clients may refer to pain as "the miseries". Based on understanding this term, the nurse should c
An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? a. it is important that you continue your medication while learning to meditate b. spiritual meditation requires a time commitment of 15 to 20 minutes daily c. obtain your healthcare provider's permission before starting medication d. complementary therapy and western medicine can be effective for you
Answer: a. it is important that you continue your medication while learning to meditate Rationale: the prolonged practice of meditation may lead to a reduced need for antihypertensive mediations. However, the medications must be continued (a) while the psychogenic response to medication is monitored. (b) is not as important as continuing the medication. The healthcare provider should be informed, but permission is not required to meditate (c). Although it is true that this complimentary therapy might be effective (d) it is essential that the client continue with antihypertensive medications until the effect of medication can be measured
During the daily nursing assessment, a client begins to cry and states that the majority of family and friends have stopped calling and visiting. What action should the nurse take? a. listen and show interest as the client expresses these feelings b. reinforce that this behavior means they were not true friends c. ask the HCP for a psych consult d. continue w/ assessment and tell the client not to worry
Answer: a. listen and show interest as the client expresses these feelings Rationale: when a client begins to cry and express feelings, a therapeutic nursing intervention is to listen and show interest as the client expresses feelings (a). (b) is not therapeutic option and the nurse does not know the dynamics of their relationships (c) is not indicated at this time. (d) is non-therapeutic and offers false hope
When assessing a client with wrist restraints, the nurse observes the fingers on the right hand are blue. What action should the nurse implement first? a. loosen the right wrist restraint b. apply a pulse oximeter to the right hand c. compare hand color bilaterally d. palpate the right radial pulse
Answer: a. loosen the right wrist restraint Rationale: the priority nursing action is to restore circulation by loosening the restraint (a) because blue fingers (cyanosis) indicated decreased circulation. (c and d) are also important nursing interventions, but do not have the priority of (a). Pulse oximetry (b) measures the saturation of hemoglobin with oxygen and is not indicated in situations where the cyanosis is related ot mechanical compression (the restraints).
A nurse is preparing to give medications through a NG feeding tube. Which nursing action should prevent complications during administration? a. mix each medication individually b. use sterile gloves for the procedure c. monitor vital signs before giving medications d. mix all mediations together to facilitate administration
Answer: a. mix each medication individually Rationale: medications should be mixed separately (a) to prevent clumping.
The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? a. observe the appearance of the skin under the ice pack b. instruct the client regarding the need for the covering c. reapply the covering after filling with fresh ice d. ask the client how long the ice was applied to the skin
Answer: a. observe the appearance of the skin under the ice pack Rationale: the first action taken by the nurse should be to assess the skin for any possible thermal injury (a). If no injury to the skin has occurred, the nurse can take the other actions b,c,d as needed.
An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? a. generalized dry skin b. localized dry skin on lower extremities c. red flush over entire skin surface d. rashes in the axillary, groin, and skin fold regions
Answer: a. rashes in the axillary, groin, and skin fold regions Rationale: immobility, constant contact with bed clothing, and excessive heat and moisture in areas where air flow is limited contributes to bacterial and fungal growth, which increases the risk for rashes (d), skin breakdown, and the development of pressure ulcers. (a,b,c) do not address the concepts of inflammation and tissue integrity
The nurse witnesses a signature of a client who has signified an informed consent. Which statement best explains this nursing responsibility? a. the client voluntarily signed the form b. the client fully understands the procedure c. the client agrees with the procedure to be done d. the client authorizes continued treatment
Answer: a. the client voluntarily signed the form Rationale: the nurse signs the consent form to witness that the client voluntarily signs the consent (a). That the client signature is authentic, and that the client is otherwise competent to give consent. It is the HCP's responsibility to ensure that the client fully understands the procedure (b). The nurse's signature does not indicate (c or d).
A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the intravenous infusion pump? a. 13 ml/hr b. 63 ml/hr c. 80 ml/hr d. 125 ml/hr
Answer: b. 63 ml/hr Rationale: 250/4 = 63
The healthcare provider prescribes an IV infusion of 1,000mL Ringer's Lactate with 30 units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by caesarean section. The tubing has been changed to a 20 gtt/mL administration set. The nurse plans to set the flow rate at how many gtt/min? a. 42 gtt/min b. 83 gtt/min c. 125 gtt/min d. 250 gtt/min
Answer: b. 83 gtt/min Rationale: 1000ml / 4 hours = 250 ml/hour 250ml/60 min = 4.1667ml/min 4.1667ml/min x 20 gtt/ml = 83.33 gtt/min
A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take 3 doses of the medication each day. Since at the time of discharge, time-released capsules are not available, which dosing schedule should the nurse advise the client to follow? a. 9 am, 1 pm, 5pm b. 8 am, 4pm, midnight c. before breakfast, before lunch, before dinner d. with breakfast, with lunch, with dinner
Answer: b. 8am, 4pm, midnight Rationale: theophylline should be administered on a regular ATC schedule (b) to provide the best bronchodilating effect and reduce the potential for adverse effects. (a,c,d) do not provide ATC dosing. (d) food may alter absorption of the med
What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? a. it is more difficult to find a superficial vein in the feet and ankles b. a decreased flow rate could result in the formation of thrombosis c. a cannulated extremity is more difficult to move when the leg or foot is used d. veins are located deep in the feet and ankles, resulting in a more painful procedure
Answer: b. a decreased flow rate could result in the formation of thrombosis Rationale: venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation (b) which if dislodged could be life-threatening. Superficial veins are often very easy (a) to find in the feet and legs. Handling a leg or foot with an IV (c) is probably not any more difficult than handling an arm or hand. Even if the nurse did believe moving a cannulated leg was more difficult, this is not the most important reason for using the upper extremities. Pain (d) is not a consideration.
The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? a. a college age track runner with a sprained ankle b. a lactating woman nursing 3 day old infant c. a school aged child with Type 2 diabetes d. an elderly man being treated for a peptic ulcer
Answer: b. a lactating woman nursing a 3 day old infant Rationale: a lactating woman (b) has the greatest need for additional protein intake. (a,c,d) are all conditions that require protein, but do not have the increased metabolic protein demands of lactation.
On admission, a client presents a signed living will that includes a DNR prescription When the client stops breathing, the nurse performs CPR. What legal issues could be brought against the nurse? a. assault b. battery c. malpractice d. false imprisionment
Answer: b. battery Rationale: civil laws protect individual rights and include international torts, such as assault (an intentional threat to engage in harmful contact with another) or battery (unwanted touching). Performing any procedure against the client wishes can potentially poise a legal issue, such as battery (b) even if the procedure is of questionable benefit to the client. (a,c,d) are not examples against the client's request
A client who is Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? a. autopsy of the body is prohibited b. blood transfusions are forbidden c. alcohol use in any form is not allowed d. vegetarian diet must be followed
Answer: b. blood transfusions are forbidden Rationale: blood transfusions are forbidden (b) in Jevoah's Witness. Judaism prohibits (a). Buddhism forbids (c) and many sects are vegetarian (d). But the direct impact on nursing care is (b).
The client's temp at 8:00 am, using an oral thermometer is 36.1° C (97.2° F). If the resp, pulse and bp are WNL, what would the nurse do next? A. Wait 15 min, retake B. Check what the client's temperature was the last time C. Retake it using a different thermometer D. Chart the temp, it is normal Feedback
Answer: b. check what the client's temperature was last time Rationale: Although the temp is slightly lower than expected, it would be best to determine the client's previous temp range next. This may be normal for the client.
The nurse notices that the mother of a 9 year old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take? a. talk directly to the child instead of the mother b. continue asking the mother questions about the child c. ask another nurse to interview the mother now d. tell the mother politely to look at you when answering
Answer: b. continue asking the mother about the child Rationale: eye contact is a culturally-influenced form of non-verbal communication. In some non-western cultures, such as the vietnamese culture, a client or family member may avoid eye contact as a form of respect, so the nurse should continue to ask the mother questions about the child (b). (a,c,d) are not indicated
The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered mediation to demonstrate correct use of the inhaler? a. immediately after exhalation b. during the inhalation c. at the end of three inhalations d. immediately after inhalation
Answer: b. during an inhalation Rationale: the client should be instructed to deliver the medication during the last part of the inhalation (b). After the medication is delivered, the client should remove mouthpiece keeping lips closed and breath held for several seconds to allow for distribution of the medication. the client should not deliver the dose as stated in (a, d) and should allow no more than 2 inhalations at a time (c)
The nurse is administering medications through a nasogastric tube which is connected to suction. After ensuring correct tube placement, what action should the nurse take next? a. clamp the tube for 20 minutes b. flush the tube with water c. administer the medications as prescribed d. crush the tablets and dissolve in sterile water
Answer: b. flush the tube with water Rationale: the NGT should be flushed before, after, and in between each medication administration (b). Once all medications are administered, the NGT should be clamped for 20 minutes (a). (c and d) may be implemented only after the tubing has been flushed.
An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feeding through a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? a. prone b. fowler's c. sims d. supine
Answer: b. fowlers Rationale: the client should be positioned in a semi-sitting fowlers position (b) during feeding to decrease the occurrence of aspiration. A gastrostomy tube known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure is inserted directly into the stomach through an incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client. (a and / c) the client is placed on the abdomen, an unsafe position for feeding. Placing a client in supine (d) position increases risk for aspiration
A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? a. administer the medication more rapidly using the same IV site b. initiate an alternate site for the IV infusion of the medication c. notify the healthcare provider before administering the next dose d. give the client a PRN dose of aspirin while the medication infuses
Answer: b. initiate an alternate site for the IV infusion of the medication Rationale: a cephalosporin antibiotic that is administered IV may cause vessel irritation. Rotating the infusion site minimizes the risk of thrombophlebitis, so an alternate infusion site should be initiated (b) before administering the next dose. Rapid administration (a) of the IV cephalosporins can potentiate vessel irritation and increase the risk of thrombophlebitis. (c) is not necessary to initiate an alternative IV site. Although aspirin has anti-inflammatory properties (d) is not indicated
Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? a. reassure the client that he will become accustomed to the stoma appearance in time b. instruct the client that the stoma will become smaller when the initial swelling diminishes c. offer to contact a member of the local ostomy support group to help him with his concerns d. encourage the client to handle the stoma equipment to gain confidence with the procedure
Answer: b. instruct the client that the stoma will become smaller when the initial swelling diminishes Rationale: postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when the swelling is diminished (b). This will help reduce the client's anxiety and promote acceptance of the colostomy. (a) does not provide helpful teaching or support. (c) is a useful action, and may be taken after the nurse provides pertinent teaching. The client is not yet demonstrating readiness to learn colostomy care (d).
Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5cm in diameter. How should the nurse record this finding? a. multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm b. localized red rash comprised of flat areas, pinpoint to 0.5cm in diameter c. several areas of red, papular lesions from pinpoint to 0.5 cm in size d. localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter
Answer: b. localized red rash comprised of flat areas, pinpoint to 0.5cm in diameter Rationale: macules are localized skin discolorations less than 1 cm in diameter. However, when recording such a finding the nurse should describe the appearance (b) rather than simply naming the condition (a). (a) identifies vesicles - an incorrect description of the symptoms listed (vesicles are fluid filled blisters). (c) identifies papules - solid elevated lesions, again not correctly identified. (d) identifies petechiae - pinpoint red to purple skin discolorations that do not itch, again is an incorrect identification
A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding stronger pain medications. What initial action is most important for the nurse to take? a. ask about any past history of drug abuse or addiction b. measure the pulse volume and capillary refill distal to the infiltration c. compress the infiltrated tissue to measure the degree of edema d. evaluate the extent of ecchymosis over the forearm area
Answer: b. measure the pulse and capillary refill distal to the infiltration Rationale: pain and diminished pulse volume (b) are signs of compartment syndrome which can progress to complete loss of the peripheral pulse in the extremity. Compartment syndrome occurs when external pressure (usually from a cast) or internal pressure (usually from subcutaneous infused fluid) exceeds capillary perfusion pressure resulting in decreased blood flow to the extremity. (a) should not be pursued until physical causes of the pain are ruled out (c) is of less priority than determining the effects of the edema on circulation and nerve function. Further assessment of the client's ecchymosis can be delayed until the signs of edema and compression suggest compartment syndrome have been examined
When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action should the nurse implement first? a. establish a new nursing diagnosis b. note which actions were not implemented c. add additional nursing orders to the plan d. collaborate with HCP to make changes
Answer: b. note which actions were not implemented Rationale: first the nurse should review which actions in the original plan were not implemented (b) in order to determine why the original plan did not produce the desired outcome. Appropriate revisions can then be made, which may include revising expected outcome, or identifying a new nursing diagnosis (a). (c) may be needed if the nursing actions were unsuccessful, or were unable to be implemented. (d) other members of the healthcare team may be necessary to collaborate changes once the nurse determines why the original plan did not produce the desired outcome
A young mother of 3 children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? a. sexual activity patterns b. nutritional history c. leisure activities d. financial stressors
Answer: b. nutritional history Rationale: caffeine, sugars, alcohol can lead to increased levels of anxiety so a nutritional history (c) should be obtained first so that health teaching can be initiated if needed. (a and c) can be used for stress management. (d) can be a source of anxiety a nutritional history should be obtained first
In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly: a. is often to be expected, and progresses with age b. often follows relocation to new surroundings c. is a result of irreversible brain pathology d. can be prevented with adequate sleep
Answer: b. often follows relocation to new surroundings Rationale: relocation (b) often results in confusion among elderly clients, moving is stressful for anyone. (a) is a stereotypical judgment. Stress in the elderly often manifests itself as confusion, so (c) is wrong. Adequate sleep is not a prevention for confusion (d).
During the admission interview, which technique is most efficient for the nurse to use when obtaining information about signs and symptoms of a client's primary health problem? a. restatement of responses b. open-ended questions c. closed-ended questions d. problem-seeking responses
Answer: b. open-ended questions Rationale: lay descriptors of health problems can be vague and nonspecific. To efficiently obtain specific information, the nurse should use closed-ended questions (c) that focus on the common signs and symptoms about a client's health problem. (a,b,d) are used when therapeutically interacting and should be used after specific information is obtained from the client
A 73 year old female client with hemiarthroplasty of the left hip due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan? a. in 8 weeks you will be able to bend at the waist to reach items on the floor b. place a pillow between your knees while lying in bed to prevent hip dislocation c. it is safe to use a walker to get out of bed, but you need assistance when walking d. take pain medication 30 minutes after your physical therapy sessions
Answer: b. place a pillow between your knees while lying in bed to prevent hip dislocation Rationale: the client's affected hip joint following a hemiarthroplasty (partial hip replacement) is at risk of dislocation for 6 months to a year following the procedure. Hip precautions to prevent dislocation include placing a pillow between the knees to maintain abduction of the hips (b). Clients should be instructed to avoid bending at the waist (a), to seek assistance for both standing and walking until they are stable on a walker or cane (c) and to take pain medication 30 minutes before physical therapy rather than waiting until the pain level is high after therapy
The nurse observes an unlicensed assistive personnel UAP taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement? a. tell the UAP to use a larger cuff at the next scheduled assessment b. reassess the client's BP with a larger cuff c. have the unit educator review this procedure with the UAP's d. teach the UAP the correct technique for assessing BP
Answer: b. reassess the client's BP with a larger cuff Rationale: the most important action is to ensure an accurate BP reading is obtained. The nurse should reassess the BP with the correct size cuff (b). Reassessment should not be postponed (a). Though (c and d) are likely indicated, these actions do not have the priority of (b)
A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the NG tube the last 2 hours. What action should the nurse take first? a. irrigate the nasogastric tube with sterile normal saline b. reposition the client on her side c. advance the nasogastric tube an additional five centimeters d. administer an intravenous antiemetic prescribed for PRN use
Answer: b. reposition the client on her side Rationale: the immediate priority is to determine if the tube is functioning properly, which could then relieve the client's nausea. The least invasive intervention (b) should be attempted first, followed by (a and c) unless either of these interventions is contraindicated. IF these measures were successful, the client may require an antiemetic (d).
The information obtained in a review of systems (ROS) is: a. objective b. subjective c. based on the nurse's perspective d. based on the physical examination findings
Answer: b. subjective Rationale: asking questions about the normal functioning of each system and the changes are usually subjective data perceived by the patient
When assessing an 82 year old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the: a. arms b. upper torso c. head d. feet
Answer: b. upper torso Rationale: The center of gravity for adults is the hips (b). However, as the person grows older, a stooped posture is common because of changes from osteoporosis and normal bone degeneration, and the knees, hips, and elbows flex. This stooped posture results in the upper torso (b) becoming the center of gravity for older persons. Although (a) is a part, or an extension of the upper torso, this is not the best and most complete answer.
During shift change report the nurse receives report that a client has abnormal heart sounds. Which placement of the stethoscope should the nurse use to hear the client's heart sounds? a. place the stethoscope bell at random points on the posterior chest b. use the stethoscope bell over the valvular areas of the anterior chest c. move the diaphragm of the stethoscope over the left anterior chest d. position the diaphragm of the stethoscope at Erb's point on the chest
Answer: b. use the stethoscope bell over the valvular areas of the anterior chest Rationale: abnormal heart sounds are best heard with the bell of the stethoscope, which picks up lower-pitched sounds, that is placed at points on the anterior chest (b). (a,c,d) do not provide the best assessment of abnormal heart valve sounds
A client who is 5'5 and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment? a. what is your daily calorie consumption? b. what vitamin and mineral supplements do you take? c. do you feel that you are overweight? d. will a clear liquid diet be okay after surgery?
Answer: b. what vitamin and mineral supplements do you take? Rationale: Vitamin and mineral supplements (b) may impact medications used during the operative period. (a and C) are appropriate questions for long-term dietary counseling. The nature of the surgery and anesthesia will determine the need for a clear liquid diet (d) rather than the client's preference.
The healthcare provider prescribes the diuretic meolazone (Zaroxolyn) 7.5 mg PO. Only available in 5 mg tablets. How much should the nurse plan to administer? a. 1/2 tablet b. 1 tablet c. 1 1/2 tablets d. 2 tablets
Answer: c. 1 1/2 tablets Rationale: 7.5 / 5 = 1.5
The nurse prepares a 1,000 ml IV of D5W to be infused over 8 hours. The infusion pump delivers 10 drops per ml. The nurse should regulate the IV line to administer how many drops per minute? a. 80 b. 8 c. 21 d. 25
Answer: c. 21 Rationale: 1000 / 8 = 125 ml/ hour 125 x 10 = 1250 drops / hour 1250 / 60 = 20.83 --> 21
The nurse is instructing a client with high cholesterol about diet and lifestyle modification. What comment from the client indicates that the teaching has been effective? a. If I exercise at least 2 times weekly for one hour, I will lower my cholesterol. b. I need to avoid eating proteins, including red meat. c. I will limit my intake of beef to 4 ounces per week. d. My blood level of low density lipoproteins needs to increase.
Answer: c. I will limit my intake of beef to 4 ounces per week. Rationale: Limiting saturated fat from animal sources to no more than 4 ounces per week (c) is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day or at least 4 to 6 times per week (a). Red meat and all proteins do not need to be eliminated (b) to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions (2 oz servings). The low density lipoproteins (d) need to decrease rather than increase.
Which response by a client with a nursing diagnosis of "Spiritual Distress" indicates to the nurse that a desired outcome measure has been met? a. expresses concern about the meaning and importance of life b. remains angry at God for the continuation of the illness c. accepts that punishment from God is not related to illness d. refuses to participate in religious rituals that have no meaning
Answer: c. accepts that punishment from God is not related to illness Rationale: acceptance that she is not being punished by God indicates a desired outcome (c) for some degree of resolution of spiritual distress. (a,b,d) do not support the concept of grief, loss, and cultural/spiritual acceptance
Gathering, verifying, and communicating data about the patient to establish a database is an example of which component of the nursing process? a. planning b. evaluation c. assessment d. implementation e. nursing diagnosis
Answer: c. assessment Rationale: identifying a patient's health care needs
During a visit to the outpatient clinic, the nurse assesses a client w/ severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? a. adequate venous blood flow to lower extremities b. estimated amount of body fat by an underarm skinfold c. degree of flexion and extension of the client's knee joint d. change in the circumference of the joint in cm
Answer: c. degree of flexion and extension of the client's knee joint Rationale: the goniometer is a 2 piece ruler that is jointed in the middle w/ a protractor type measuring device that is placed over a joint as the individual extends or flexes the joint to measure the degrees of flexion and extension on the protractor (c). A doppler is used to measure blood flow (a) Calipers are used to measure body fat (b). A tape measure is used to measure circumference of body parts (d).
A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client: a. asks relevant questions regarding the dressing change b. states he will be able to complete the wound care regimen c. demonstrates the wound care procedure correctly d. has all the necessary supplies for wound care
Answer: c. demonstrates the wound care procedure correctly Rationale: a return demonstration for a procedure (c) provides an objective assessment of the client's ability to perform a task, while (a and b) are subjective measures. (d) is important but is less of a priority to discharge than the nurse's assessment of the client's ability to complete the wound care
Which assessment data provides the most accurate determination of proper placement of a nasogastric tube? a. aspirating gastric contents to assure a pH value of 4 or less b. hearing air pass in the stomach after injecting air into the tubing c. examining a chest x-ray obtained after the tubing was inserted d. checking the remaining length of tubing to ensure that the correct length was inserted
Answer: c. examining a chest x-ray obtained after tubing was inserted Rationale: both a and b are methods used to determine proper placement of NG tubing. However, the best indicator is c. D is not an indicator of proper placement
What action should the nurse implement when accessing an implanted infusion port for a client who receives long term IV medications? a. cleanse the site with iodine solution b. insert a Huber-point needle into the port c. flush tubing w/ 5 ml of normal saline d. place a sterile dressing over the port
Answer: c. flush tubing w/ 5Ml of NS Rationale: an impacted infusion port needs to be accessed using a Huber-point needle (b) non-coring to prevent damage to the self-sealing septum of the port. (a,c,d) are not necessary when accessing an implanted infusion port
The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? a. thalamus b. hypothalamus c. frontal lobe d. parietal lobe
Answer: c. frontal lobe Rationale: the frontal lobe (c) of the cerebrum controls higher mental activities, such as memory, intellect, language, emotions, and personality. (a) is an afferent relay center in the brain that directs impulses to the cerebral cortex. (b) regulates body temperature, appetite, maintains a wakeful state, and links higher centers with the autonomic nervous and endocrine system, such as the pituitary. (d) is the location of the sensory and motor functions.
A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record? a. healthcare provider notified of failure to collect specimens for prescribed blood studies b. blood specimens not collected because client no longer wants blood tests performed c. health care provider notified of client's refusal to have blood specimens collected for testing d. client irritable, uncooperative, and refuses to have blood collected. Health care provider notified.
Answer: c. healthcare provider notified of client's refusal to have blood specimens collected for testing Rationale: when a client refuses a treatment, the exact words of the client regarding the client's refusal of care should be documented in a narrative format (c). (a,b,d) do not address the concepts of informatics and legal issues
The nurse is caring for a client who is receiving 24 hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? a. infuse normal saline at a keep vein open rate b. discontinue the IV and flush the port with heparin c. infuse 10% dextrose and water at 54 ml/hr d. obtain a stat blood glucose level and notify the HCP
Answer: c. infuse 10% dextrose and water at 54 ml/hr Rationale: TPN is discontinued gradually to allow the client to adjust to decreased levels of glucose. Administering 10% dextrose in water at the prescribed rate (c) will keep the client from experiencing hypoglycemia until the next TPN solution is available. The client could experience a hypoglycemic reaction if the current level of glucose (a) is not maintained or if the TPN is discontinued abruptly (b). There is no reason to obtain a stat blood glucose level (d) and the HCP cannot do anything about this situation.
At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence? a. it is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel. b. looking at your incision can be frightening, but facing the fear is a necessary part of your recovery c. it is OK if you don't want to talk about your surgery. I will be available to you when you are ready d. i will ask a woman who has had a mastectomy to come by and share her experiences with you
Answer: c. it is OK if you don't want to talk about your surgery. I will be available to you when you are ready. Rationale: (c) displays sensitivity and understanding without judging the client. (a) is judgmental in that telling the client how she feels and is also insensitive. (b) would give the client a chance to talk, but it is also demanding and demeaning. (d) displays a positive action, but because the nurse's personal support is not offered, this response could be interpreted as dismissing the client and avoiding the problem
Which action is most important for the nurse to implement when donning sterile gloves? a. maintain thumb at a 90 degree angle b. hold hands with fingers down while gloving c. keep gloved hands above the elbows d. put the glove on the dominant hand first
Answer: c. keep gloved hands above the elbows Rationale: gloved hands below waist level are considered unsterile (c). (a and b) are not essential to maintaining asepsis. While it may be helpful to put the glove on the dominant hand first (d) it is not necessary to ensure asepsis
When conducting an admission assessment, the nurse should ask the client about the use of complementary healing practices. Which statement is accurate regarding the use of these practices? a. complimentary healing practices interfere with the efficacy of the medical model of treatment b. conventional medications are likely to interact with folk remedies and cause adverse effects c. many complimentary healing practices can be used in conjunction with conventional practices d. conventional medical practices will ultimately replace the use of complementary healing practices
Answer: c. many complimentary healing practices can be used in conjunction with conventional practices Rationale: conventional approaches to health care can be depersonalizing and often fail to take into consideration all aspects of an individual, including body, mind, and spirit. Often complimentary healing practices can be used in conjunction with conventional medical practices (c) rahter than interfering (a) causing adverse effects (b) or replacing conventional medical care (d)
Mr. Davis tells the nurse that he has been experiencing more frequent episodes of indigestion. The nurse asks if the indigestion is associated with meals or a reclining position and asks what relieves the indigestion. This is an example of which interview technique? a. direct question b. problem solving c. problem seeking d. open ended question
Answer: c. problem seeking Rationale: takes information provided in the patient's story and then more fully describes and identifies specific problem areas
The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? a. remain calm with the client and record abnormal results in chart b. notify the medication nurse immediately if the pule or blood pressure is low c. report the results of the vital signs to the nurse d. reassure the client that the vital signs are normal
Answer: c. report the results of the vital signs to the nurse Rationale: interpretation of the vital signs is the responsibility of the nurse, so the UAP should report vital sign measurements to the nurse (c). (a,b,d) require the UAP to interpret the vital signs, which is beyond the UAP's authority
An UAP places a client in the left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide to the UAP? a. position the client on the right side of the bed in reverse Trendelenburg b. fill the enema container with 1000 ml of warm water and 5 ml of castile soap c. reposition in a sim's position with the client's weight on the anterior illium d. raise the side rails on both sides of the bed and elevate the bed to waist level
Answer: c. reposition in a Sim's position with the client's weight on the anterior ilium Rationale: the left sided Sim's position allows the enema solution to follow the anatomical course of the intestines and allows the best overall results, so the UAP should reposition the client in the Sim's position, which distributes the client's weight to the anterior illium (c). A is inaccurate (b and d) should be implemented once the client is positioned
The planning step of the nursing process includes: a. assessing and diagnosing b. evaluating goal achievement c. setting goals and selecting interventions d. performing nursing actions and documenting them
Answer: c. setting goals and selecting interventions Rationale: the nurse sets patient centered goals and expected outcomes and plans nursing interventions
The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that the client understands dietary restrictions? a. tossed salad, low sodium dressing, bacon and tomato sandwich b. Clam chowder, no salt crackers, fresh fruit salad c. skim milk, turkey salad, and vanilla ice cream d. macaroni and cheese, diet coke, and a slice of cherry pie
Answer: c. skim milk, turkey salad, roll, and vanilla ice cream Rationale: food choices in (c) while containing some sodium are considered low sodium foods. Bacon (a), canned soups (b), macaroni, hard cheese, soda, (d) are very high in sodium
A hospitalized male patient is receiving nasogastric feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but now feels fine. What action is the best for the nurse to take? a. record the coughing incident. No further action is required at this time b. stop the feeding, explain to the family why it is being stopped, and notify HCP c. after clearing the tube with 30mL of air, check the pH of fluid withdrawn from the tube d. inject 30 mL of air into the tube while auscultating the epigastrium for gurgling
Answer: c. stop the feeding, explain to the family why it is being stopped, and notify HCP Rationale: Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking any further action (c). (a) and (b) are not indicated. The auscultating method (d) has been found to be unreliable for small-bore feeding tubes.
An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? a. a nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes b. the nurse assigned to care for the client who was at lunch at the time of the fall c. the nurse who transferred the client to the chair when the fall occurred d. the charge nurse who completed rounds 30 minutes before the fall occurred
Answer: c. the nurse who transferred the client to the chair when the fall occurred Rationale: the four elements of malpractice are: 1) breach of duty owed 2) failure to adhere to the recognized standard of care 3) direct causation of injury 4) evidence of actual injury. The hip fracture is the actual injury and the standard of care was "frequent monitoring". (c) implies that duty was owed and the injury occurred while the nurse was in charge of the client's care, there is no evidence in (a,b,d).
The nurse notices the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids including gelatin, popsicles, juices, remain untouched. What explanation is most appropriate for this behavior? a. the belief is held that the "evil eye" enters the child if anything cold is ingested b. after surgery the child probably has refused all foods except broth c. eating broth strengthens the child's innate energy called "chi" d. "hot remedies" restore balance after surgery, which is considered a "cold" condition
Answer: d. "hot remedies" restore balance after surgery, which is considered a "cold" condition Rationale: common parental practices and health beliefs among Hispanic, Chinese, Filipino, and Arab cultures classify diseases, areas of the body, and illness as "hot" or "cold" and must be balanced to maintain health and prevent illness. The perception that surgery is a "cold" condition implies that only "hot" remedies, such as soup, should be used to restore the healthy balance within the body so (d) is the correct interpretation. (a,b,c) are not correct interpretations. "chi" is a Chinese belief that an innate energy enters and leaves the body via certain locations and pathways and maintains health. The "evil eye" or "mal ojo" believed by many cultures to be related to the balance of health and illness but is unrelated to diet.
The nurse mixes 50 mg of Nipride in 250mL of D5W and plans to administer the solution at a rate of 5mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60gtt/mL how many drops per minute should the client receive? a. 31 gtt/min b. 62 gtt/min c. 93 gtt/min d. 124 gtt/min
Answer: d. 124 gtt/min Rationale: d is the correct calculation: 182/2.2 = 82.73 kg 5mcg x 82.73 = 413.65 mcg/min. 250/50,000mcg = 200 mcg/ml 413.65/200 = 2.07 mL 60 x 2.07 = 124.28 gtt/min
An IV infusion terbutaline sulfate 5 mg in 500 ml of D5W infusing at a rate of 30 mcg/min is prescribed for a client in premature labor. How many ml/hr should the nurse set the infusion pump? a. 30 b. 60 c. 120 d. 180
Answer: d. 180 Rationale: 500ml 1 mg 30mcg 60 min ______________ X ____________ X _____________ X _________ = 180 5 mg 1000 mcg 1 min 1 hour
Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? a. apply a condom catheter b. apply a skin protectant c. encourage increased fluid intake d. assess for bladder distention
Answer: d. assess for bladder distention Rationale: urinary retention is the inability to void all urine collected in the bladder, which leads to uncomfortable bladder distention (d). (a and b) are useful actions to protect the skin of a client with urinary incontinence, (c) may worsen bladder distention
During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? a. provide additional coffee on the client's breakfast tray b. exchange the client's grape juice for cranberry c. bring the client additional fruit at mid-morning d. encourage additional oral intake of juices and water
Answer: d. encourage additional oral intake of juices and water Rationale: dark amber urine is characteristic of fluid volume deficit, and the client should be encouraged to increase fluid intake (d). Caffeine is a diuretic (a) and may worsen the fluid volume deficit. Any type of juice will be beneficial (b) since the client is not dysuric a sign of UTI. The client needs to restore fluid volume more than solid foods (c).
A client with acute hemorrhagic anemia is to receive four units of packed RBC's as rapidly as possible. Which intervention is most important for the nurse to implement? a. obtain the pre-transfusion hemoglobin level b. prime the tubing and prepare a blood pump set-up c. monitor vital signs q15 minutes for the first hour d. ensure the accuracy of the blood type match
Answer: d. ensure the accuracy of the blood match type Rationale: all interventions should be implemented when administering blood, but (d) has the highest priority. Any time blood is administered, the nurse should ensure the accuracy of the blood type match in order to prevent a possible hemolytic reaction.
Clinical decision making requires the nurse to: a. improve the patient's health b. standardize care for the patient c. follow the health care provider's orders for patient care d. establish and weigh criteria in deciding the best choice of therapy for a patient
Answer: d. establish and weigh criteria in deciding the best choice of therapy for a patient Rationale: involves recognizing an issue exists, analyzing information, evaluating information, and making conclusions
The following statements appear on a nursing care plan for a patient after a mastectomy "incision site approximated, absence of drainage or prolonged erythema at incision site, and patient remains afebrile". These statements are examples of: a. long term goal b. short term goal c. nursing diagnosis d. expected outcome
Answer: d. expected outcome Rationale: the measurable change in a patient's condition that you expect to occur in response to nursing care
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? a. massage any reddened areas for at least 5 minutes b. encourage active range of motion exercises on extremities c. position the client laterally, prone, and dorsally in sequence d. gently lift the client when moving into a desired position
Answer: d. gently lift the client when moving into a desired position Rationale: to avoid shearing forces when repositioning, the client should be lifted gently across a surface (d). Reddened areas should not be massaged (a) since this may increase damage to already traumatized skin. To control pain and muscle spasms, active range of motion (b) may be limited on the affected leg. The position described in (c) is contraindicated for a client with a fractured left hip
A client is in the radiology department at 0900 when the prescription for Levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? a. contact the healthcare provider and complete a medication variance form b. administer the levaquin at 1300 and resume the 0900 schedule in the morning c. notify the charge nurse and complete an incident report to explain the missed dose d. give the missed dose at 1300 and change the schedule to administer daily at 1300
Answer: d. give the missed dose at 1300 and change the schedule to administer daily at 1300 Rationale: to ensure that a therapeutic level of mediation is maintained, the nurse should administer the missed dose as soon as possible, and revise the administration schedule accordingly to prevent dangerously increasing the level of medication in the bloodstream (d). The nurse should document the reason for the late dose but (a and c) are not warranted. (b) could result in increased blood levels of the drug
The first part of the nursing diagnosis statement: a. may be states as a medical diagnosis b. identifies the cause of the patient problem c. identifies appropriate nursing interventions d. identifies an actual or potential health problem
Answer: d. identifies an actual or potential health problem Rationale: it is the diagnostic label that describes the essence of a patient's response to health conditions
At the beginning of the shift, the nurse assesses a client who is admitted from the post-anesthesia care unit (PACU). When should the nurse document the client's findings? a. at the beginning, middle, and end of the shift b. after client priorities are identified for the development of the nursing care plan c. at the end of the shift is so full attention can be given to the client's needs d. immediately after the assessments are completed
Answer: d. immediately after the assessments are completed Rationale: documentation should occur immediately after any component of the nursing process, so assessments should be entered in the client's medical record as readily as findings are obtained (d). (a,b,c) do not address the concepts of legal recommendations for information management and informatics
A nursing diagnosis: a. identifies nursing problems b. is not changed during the course of a patient's hospitalization c. is derived from the physician's history and physical examination d. is a statement of a patient response to a health problem that requires nursing intervention
Answer: d. is a statement of a patient response to a health problem that requires nursing intervention Rationale: provide the basis for the selection of nursing interventions to achieve outcomes for which the nurse is responsible
The second part of the nursing diagnosis statement: a. is usually stated as a medical diagnosis b. identifies the expected outcomes of nursing care c. identifies the probable cause of the patient problem d. is connected to the first part of the statement with the phrase "related to"
Answer: d. is connected to the first part of the statement with the phrase "related to" Rationale: it is associated with the patient's actual or potential response to the health problem
A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? a. demonstrate loss of remote memory b. exhibits expressive dysphagia c. has a diminished attention span d. is disoriented to place and time
Answer: d. is disoriented to place and time Rationale: The client is exhibiting disorientation (d). (a) refers to memory of the distant past. The client is able to express himself without difficulty (b) and does not demonstrate a diminished attention span (c).
The UAP's working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? a. place the chair at a right angle to the bed on the client's left side before moving b. assist the client to a standing position, then place the right hand on the armrest c. have the client place the left foot next to the chair and pivot to the left before sitting d. move the chair parallel to the right side of the bed, and stand the client on the right foot
Answer: d. move the chair parallel to the right side of the bed and stand the client on the right foot Rationale: (d) uses the patient's stronger side, the right side, for weight-bearing during the transfer which is the strongest approach. (a,b,c) are unsafe methods of transfer and include the use of poor body mechanics by the caregiver
An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? a. reaffirm the client's desire for no resuscitative efforts b. transfer the client to a hospice inpatient facility c. prepare the family for the client's impending death d. notify the HCP of the family's request
Answer: d. notify the healthcare provider of the family's request Rationale: the nurse should first communicate with the healthcare provider (d). Hospice care is provided for clients with a limited life expectancy, which must be identified by the healthcare provider. (a) is not necessary at this time. Once the healthcare provider supports the transfer to hospice care, the nurse can collaborate with the hospice staff and health care provider to determine when (b and c) should be implemented
The interview technique that is most effective in strengthening the nurse-patient relationship by demonstrating the nurse's willingness to hear the patient's thoughts is: a. direct question b. problem solving c. problem seeking d. open ended question
Answer: d. open ended question Rationale: prompts patients to describe a situation in more than 2 words
The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for 15 seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? a. encourage the client to cough to help loosen secretions b. advise the client to increase the intake of oral fluids c. rotate the suction catheter to obtain any remaining secretions d. re-oxygenate the client before attempting to suction again
Answer: d. re-oxygenate the client before attempting to suction again Rationale: suctioning should not be continued for longer than 10-15 seconds, since the client's oxygenation is compromised during this dime (d). (a,b,c) may be performed after the client is re-oxygenated and additional suctioning is performed
A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take? a. explain that anyone who speaks her language can answer the questions b. provide a translator only in an emergency situation c. ask a family member or friend of the client to translate d. request and document the name of a certified translator
Answer: d. request and document the name of a certified translator Rationale: a certified translator should be requested to ensure the exchanged information is reliable and unaltered. To adhere to legal requirements in some states, the name of the translator should be documented (d). Client information that is translated is private under HIPAA rules so (a) is not the best action. Although an emergency situation may require extenuating circumstances (b) a translator should be provided in most situations. Family members may skew information and not translate the exact information so (c) is not preferred.
A Sub-Saharan African widowed immigrant woman lives with her deceased husband's brother and family, which includes the brother-in-law's children and the widow's adult children. Each family member speaks fluent English. Surgery was recommended for the client. What is the best plan to obtain consent for surgery for this client? a. obtain an interpreter to explain the procedure to the client b. encourage the client to make her own decision regarding surgery c. ask the family members to provide a clarification of the surgeon's explanation to the client d. tell the surgeon that the brother-in-law will decide after explanation of the proposed surgery is provided to him and the window
Answer: d. tell the surgeon that the brother-in-law will decide after explanation of the proposed surgery is provided to him and the window Rationale: Customary law in some rural Sub-Saharan countries encompasses wife inheritance and polygamy; the widow becomes the inherited wife of her husband's brother. In those rural areas women live in a patriarchal family where decisions are made by men. Most likely, the brother-in-law will make the decision for his inherited wife so (d) provides the surgeon with culturally sensitive information. (a) all family members members speak fluent English therefore there is no need for translation. It is culturally insensitive to encourage the woman to go against her wishes and her cultural worldview as in (b). Family members are more likely to misinterpret medical information (c).
20 minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse? a. that means you have derived the maximum benefit and the heat can be removed b. your blood vessels are becoming dilated and removing the heat from the site c. we will increase the temperature 5 degrees when the pad no longer feels warm d. the body's receptors adapt over time as they are exposed to heat
Answer: d. the body's receptors adapt over time as they are exposed to heat Rationale: (d) describes thermal adaptation, which occurs 20 to 30 minutes after heat application. (a and b) provide false information (c) is not based on a knowledge of physiology and is an unsafe action that may harm the client
Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent? a. height in inches or cm b. weight in kg or pounds c. triceps skin fold thickness d. upper arm circumfrence
Answer: d. upper arm circumference Rationale: upper arm circumference (d) is an indirect measure of muscle mass. (a and B0 do not distinguish fat from muscle (c) is a measure of body fat
55.A 4-year-old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse, Will it hurt to have my tonsils and adenoids taken out? Which response is best for the nurse to provide? A. It may hurt a little because of the incision made in your throat. B. It won't hurt because you're such a big boy. C. It won't hurt because we put you to sleep. D. It may hurt but we'll give you medicine to help you feel better.
Answering questions simply and directly provides comfort for the preschool-age child and builds confidence in the health care team (D). (A) uses language (i.e. 'incision') that could create anxiety for the child. Four-year-olds are in the Initiative vs. Guilt stage (Erikson's psychosocial development), and (B) contributes to guilt when the child hurts. (C) is not helpful because the child may associate being put to sleep with the postoperative throat pain and then become fearful of going to sleep. Correct Answer: D
A male client who had abdominal surgery has a NG tube and complains of dry mouth. Which action should the nurse implement?
Apply a water soluble lubricant to the lips, oral mucosa, and nares. Petroleum based products are flammable
Assessing both lower extremities with chronic venous insufficiency, identifies bilateral stasis dermatitis and an ulcer in the medial surface of the left ankle. To promote effective self-care what teaching?
Apply compression stockings before ambulation
Nurse teaching male with multiple sclerosis (MS) how to empty bladder using creude method. When performing return demonstration patient applies pressure to the umbilical area of his abdomen
Apply downward manual pressure at the suprapubic region
The nurse is interviewing a female client whose spouse is preset. During the interview the spouse answers most of the questions for the client. Which action is best for the nurse to implement?
Ask the spouse to step out for a few minutes.
22.When preparing to administer an intravenous medication through a central venous catheter, the nurse aspirates a blood return in one of the lumens of the triple lumen catheter. Which action should the nurse implement? A. Flush the lumen with the saline solution and administer the medication through the lumen. B. Determine if a PRN prescription for a thrombolytic agent is listed on the medication record. C. Clamp the lumen and obtain a syringe of a dilute heparin solution to flush through the tubing. D. Withdraw the aspirated blood into the syringe and use a new syringe to administer the medication.
Aspiration of a blood return in the lumen of a central venous catheter indicates that the catheter is in place and the medication can be administered. The nurse should flush the tubing with the saline solution, administer the medication (A), then flush the lumen with saline again. (B and C) are not necessary. The aspirated blood can be flushed back through the closed system into the client's bloodstream, but does not need to be withdrawn (D). Correct Answer: A
A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first?
Assist the ambulating client back to the bed.
Acls and cpr asap!
Asystole
Sawtooth Atrial rate 250-350 Ventricular rate is steady Cardioversion, cardizem (verapamil), amiodarone
Atrial flutter
A nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? a. "I will place the client on his side." b. "I will go to the nurses' station for assistance." c. "I will administer his medications." d. "I will prepare to insert an airway."
B
The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the nurse administer? A) 1 ml. B) 1.5 ml. C) 1.75 ml. D) 2 ml.
B) 1.5 ml
A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump? A) 13 ml/hour. B) 63 ml/hour. C) 80 ml/hour. D) 125 ml/hour
B) 63 ml/hour
A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? A) 9 a.m., 1 p.m., and 5 p.m. B) 8 a.m., 4 p.m., and midnight. C) Before breakfast, before lunch and before dinner. D) With breakfast, with lunch, and with dinner.
B) 8 a.m., 4 p.m., and midnight Theophylline should be administered on a regular around-the-clock schedule (B) to provide the best bronchodilating effect and reduce the potential for adverse effects. (A, C, and D) do not provide around-the-clock dosing. Food may alter absorption of the medication (D).
What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A) It is more difficult to find a superficial vein in the feet and ankles. B) A decreased flow rate could result in the formation of a thrombosis. C) A cannulated extremity is more difficult to move when the leg or foot is used. D) Veins are located deep in the feet and ankles, resulting in a more painful procedure
B) A decreased flow rate could result in the formation of a thrombosis Venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation (B) which, if dislodged, could be life-threatening. Superficial veins are often very easy (A) to find in the feet and legs. Handling a leg or foot with an IV (C) is probably not any more difficult than handling an arm or hand. Even if the nurse did believe moving a cannulated leg was more difficult, this is not the most important reason for using the upper extremities. Pain (D) is not a consideration
The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A) A college-age track runner with a sprained ankle. B) A lactating woman nursing her 3-day-old infant. C) A school-aged child with Type 2 diabetes. D) An elderly man being treated for a peptic ulcer.
B) A lactating woman nursing her 3-day-old infant A lactating woman (B) has the greatest need for additional protein intake. (A, C, and D) are all conditions that require protein, but do not have the increased metabolic protein demands of lactation
On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? A) Assault. B) Battery. C) Malpractice. D) False imprisonment.
B) Battery Civil laws protect individual rights and include intentional torts, such as assault (an intentional threat to engage in harmful contact with another) or battery (unwanted touching). Performing any procedure against the client's wishes can potentially poise a legal issue, such as battery (B), even if the procedure is of questionable benefit to the client. (A, C, and D) are not examples against the client's request
A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? A) Autopsy of the body is prohibited. B) Blood transfusions are forbidden. C) Alcohol use in any form is not allowed. D) A vegetarian diet must be followed
B) Blood transfusions are forbidden Blood transfusions are forbidden (B) in the Jehovah's Witness religion. Judaism prohibits (A). Buddhism forbids the use of (C) and drugs. Many of these sects are vegetarian (D), but the direct impact on nursing care is (B).
A parent calls the pediatrician's office frantic because her 2-year-old son drank a bottle of cleaner. Which of the following is the most important instruction the nurse can give to this parent? A) Give the child milk. B) Call the poison control center. C) Give the child syrup of ipecac. D) Take the child to the emergency department.
B) Call the poison control center. The poison control center will direct all care given to a child who has ingested a substance. Based on the description of the poison, poison control center staff will tell the parent whether the child needs to go to the emergency department and what substances should be given to the child
The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? A) Immediately after exhalation. B) During the inhalation. C) At the end of three inhalations. D) Immediately after inhalation
B) During the inhalation The client should be instructed to deliver the medication during the last part of inhalation (B). After the medication is delivered, the client should remove the mouthpiece, keeping his/her lips closed and breath held for several seconds to allow for distribution of the medication. The client should not deliver the dose as stated in (A or D), and should deliver no more than two inhalations at a time (C).
A client is isolated because the client has pulmonary tuberculosis. The nurse notes that the client seems angry but knows this is a normal response to isolation. The best intervention is to: A) Provide a dark, quiet room to calm the client. B) Explain the isolation procedures and provide meaningful stimulation. C) Reduce the level of precautions to keep the client from becoming angry. D) Limit family and other caregiver visits to reduce the risk of spreading the infection.
B) Explain the isolation procedures and provide meaningful stimulation. When a client is in isolation, the nurse should take measures to improve the client's stimulation and make sure to explain the isolation procedures. Darkening the room can increase the sense of isolation. The nurse should not change the isolation level but should provide plenty of emotional support and make time for the client to prevent a sense of isolation. As long as family and caregivers follow infection precautions, there is no reason to limit contact with these individuals.
An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? A) Prone. B) Fowler's. C) Sims'. D) Supine.
B) Fowler's The client should be positioned in a semi-sitting (Fowler's) (B) position during feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into the stomach through an incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client. In (A and/or C), the client is placed on the abdomen, an unsafe position for feeding. Placing the client in (D) increases the risk of aspiration
An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The nurse knows that the best position for this client during administration of the feedings is A) prone. B) Fowler's. C) Sims'. D) supine
B) Fowler's The client should be positioned in a semi-sitting (Fowler's) (B) position during feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into the stomach through an incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client. In (A and/or C), the client is placed on the abdomen, an unsafe position for feeding. Placing the client in (D) increases the risk of aspiration
The family of the nurse's confused, ambulatory client insists that all four side rails be up when the client is alone. The best way to handle this situation is to: A) Ask them to stay with the client at all times. B) Inform them of the risks associated with side rail use. C) Thank them for being conscientious and put the four rails up. D) Provide the client with a one-to-one sitter while the side rails are up
B) Inform them of the risks associated with side rail use. The use of side rails when a client is disoriented will cause more confusion and further injury. A confused client who is determined to get out of bed may attempt to climb over the side rail or climb out at the foot of the bed, and may fall or experience other injury. After the nurse has this discussion with the family, then the nurse should perform a thorough nursing assessment and develop a plan to ensure the client's safety.
A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? A) Administer the medication more rapidly using the same IV site. B) Initiate an alternate site for the IV infusion of the medication. C) Notify the healthcare provider before administering the next dose. D) Give the client a PRN dose of aspirin while the medication infuses
B) Initiate an alternate site for the IV infusion of the medication A cephalosporin antibiotic that is administered IV may cause vessel irritation. Rotating the infusion site minimizes the risk of thrombophlebitis, so an alternate infusion site should be initiated (B) before administering the next dose. Rapid administration (A) of intravenous cephalosporins can potentiate vessel irritation and increase the risk of thrombophlebitis. (C) is not necessary to initiate an alternative IV site. Although aspirin has antiinflammatory actions, (D) is not indicated
Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? A) Reassure the client that he will become accustomed to the stoma appearance in time. B) Instruct the client that the stoma will become smaller when the initial swelling diminishes. C) Offer to contact a member of the local ostomy support group to help him with his concerns. D) Encourage the client to handle the stoma equipment to gain confidence with the procedure
B) Instruct the client that the stoma will become smaller when the initial swelling diminishes Postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when the swelling is diminished (B). This will help reduce the client's anxiety and promote acceptance of the colostomy. (A) does not provide helpful teaching or support. (C) is a useful action, and may be taken after the nurse provides pertinent teaching. The client is not yet demonstrating readiness to learn colostomy care (D).
Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? A) Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. B) Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. C) Several areas of red, papular lesions from pinpoint to 0.5 cm in size. D) Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter.
B) Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter Macules are localized flat skin discolorations less than 1 cm in diameter. However, when recording such a finding the nurse should describe the appearance (B) rather than simply naming the condition. (A) identifies vesicles -- fluid filled blisters -- an incorrect description given the symptoms listed. (C) identifies papules -- solid elevated lesions, again not correctly identifying the symptoms. (D) identifies petechiae -- pinpoint red to purple skin discolorations that do not itch, again an incorrect identification
A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? A) Sexual activity patterns. B) Nutritional history. C) Leisure activities. D) Financial stressors
B) Nutritional history Caffeine, sugars, and alcohol can lead to increased levels of anxiety, so a nutritional history (C) should be obtained first so that health teaching can be initiated if indicated. (A and C) can be used for stress management. Though (D) can be a source of anxiety, a nutritional history should be obtained first
A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first? A) Irrigate the nasogastric tube with sterile normal saline. B) Reposition the client on her side. C) Advance the nasogastric tube an additional five centimeters. D) Administer an intravenous antiemetic prescribed for PRN use.
B) Reposition the client on her side The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention, (B), should be attempted first, followed by (A and C), unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require an antiemetic (D).
When providing health maintenance teaching to new employees in the food-handling department, the nurse emphasizes the need to perform hand hygiene after using the bathroom to prevent: A) Food poisoning B) Spread of hepatitis A C) Bacterial food infections D) Salmonella contamination
B) Spread of hepatitis A The hepatitis A virus is spread via fecal contamination of food, water, or milk. It is essential that food handlers wash their hands anytime they use the bathroom. Food poisoning can be due to bacterial contamination of food from a variety of sources, but not usually feces. Salmonella contamination usually arises from uncooked eggs.
When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the A) Arms. B) Upper torso. C) Head. D) Feet
B) Upper torso The center of gravity for adults is the hips. However, as the person grows older, a stooped posture is common because of the changes from osteoporosis and normal bone degeneration, and the knees, hips, and elbows flex. This stooped posture results in the upper torso (B) becoming the center of gravity for older persons. Although (A) is a part, or an extension of the upper torso, this is not the best and most complete answer.
The nurse has just admitted a client to rule out active hepatitis B. The client is confused, spitting and scratching everyone who enters the room. The nurse should: A) Wait an hour until the client calms down and then use gloves when touching the client. B) Use gloves, mask, face shield, and gown when entering the room to perform the initial assessment. C) Administer a sedative and then perform the assessment after the client is asleep; no precautions would be needed. D) Realize that isolation equipment might further confuse the client and avoid using a face mask and shield but use gown and gloves.
B) Use gloves, mask, face shield, and gown when entering the room to perform the initial assessment. Hepatitis virus is a blood-borne virus, but the client is increasing the risk of cross contamination by spitting (saliva can be a source of bacterial contamination) and scratching others, which can break the skin and become a source of risk. All of the barriers listed would minimize cross contamination from the client to the nurse. Even though gloves may be all that is needed because of limited contact with the client, after an hour the client will remain confused and may not understand. The client may become aggressive again and spit or scratch, and other barriers are needed to stop that source of possible risks. A sedative may be given if needed, but trying to perform an assessment when the client is asleep is not appropriate and will prevent the nurse from successfully establishing rapport with the client. Although masks and shields might be frightening to some confused clients, if the client is spitting and body fluids could be exchanged, a barrier should still be used.
In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly A) is to be expected, and progresses with age. B) often follows relocation to new surroundings. C) is a result of irreversible brain pathology. D) can be prevented with adequate sleep
B) often follows relocation to new surroundings Relocation (B) often results in confusion among elderly clients--moving is stressful for anyone. (A) is a stereotypical judgment. Stress in the elderly often manifests itself as confusion, so (C) is wrong. Adequate sleep is not a prevention (D) for confusion
A nurse is caring for an adolescent client who is 2 days postoperative following an appendectomy and has type I diabetes mellitus. The client is tolerating a regular diet. He has ambulated successfully around the unit with assistance. He requests pain medication every 6 to 8 hr while reporting pain at a 2 on a scale of 0 to 10 after receiving the medication. His incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? Select all that apply. a. Extremes in age b. Impaired circulation c. Impaired/suppressed immune system d. Malnutrition e. Poor wound care
B, C
A nurse educator is discussing the facility protocol in the event of a tornado with the staff. Which of the following should the nurse include in the instructions? Select all that apply. a. Open doors to client rooms b. Place blankets over the clients who are confined to beds c. Move beds away from the windows d. Draw shades and close drapes e. Instruct ambulatory clients in the hallways to return to their rooms
B, C, D
A nurse educator is reviewing proper body mechanisms during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? Select all that apply. a. "My line of gravity should fall outside my base of support." b. "The lower my center of gravity, the more stability I have." c. "To broaden my base of support, I should spread my feet apart." d. "When I lift an object, I should hold it as close to my body as possible." e. "When pulling an object, I should move my front foot forward."
B, C, D
A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? Select all that apply. a. The provider drops a sterile instrument onto the near side of the sterile field b. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field c. The procedure is delayed 1 hr because the provider receives an emergency call d. The nurse turns to speak to someone who enters through the door behind the nurse e. The client's hand brushes against the outer edge of the sterile field
B, C, D
A nurse is caring for a client receiving dextrose 5% in 0.9% sodium chloride IV at 120 mL/hr. Which of the following statements by the client should alert the nurse to suspect fluid overload? Select all that apply. a. "I feel lightheaded." b. "I feel as though my heart is racing." c. "I feel a little short of breath." d. "The nurse technician told me that my blood pressure was 150 over 90." e. "I think my ankles are less swollen."
B, C, D
A nurse is caring for a client who has had diarrhea for 4 days. When assessing the client, the nurse should expect which of the following findings? Select all that apply. a. Bradycardia b. Hypotension c. Elevated temperature d. Poor skin turgor e. Peripheral edema
B, C, D
A nurse is collecting data from an older adult client as part of a neurosensory examination. Which of the following findings should the nurse expect as changes associated with aging? Select all that apply. a. Slower light touch sensation b. Some vision and hearing decline c. Slower fine finger movement d. Some short-term memory decline e. Slower superficial pain sensation
B, C, D
A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? Select all that apply a. The roommate ambulates independently b. The client ambulates with his slippers on over his antiembolic stockings c. The client uses a front-wheeled walker when ambulating d. The client had pain medication 30 min ago e. The client is allergic to codeine f. The client ate 50% if his breakfast this morning
B, C, D
A nurse is preparing medications for a preschooler. Which of the following factors should the nurse identify as altering how a medication affects children? Select all that apply. a. Increased gastric acid production b. Lower blood pressure c. Higher body water content d. Increased absorption of topical medications e. Increased gastric emptying time
B, C, D
A nurse is preparing to initiate a bladder-retaining program for a client who has incontinence. Which of the following actions should the nurse take? Select all that apply. a. Establish a schedule of urinating prior to meal times b. Have the client record urination times c. Gradually increase the urination intervals d. Remind the client to hold urine until the next scheduled urination time e. Provide a sterile container for urine
B, C, D
A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include to address common health risks for this age group? Select all that apply. a. Install bath rails and grab bars in bathrooms b. Wear a helmet while skiing c. Install a carbon monoxide detector d. Secure firearms in a safe location e. Remove throw rugs from the home
B, C, D
The mother of a 7-month-old infant tells the nurse at the pediatric clinic that her baby has been fussy with occasional loose stools since she started feeding him fruits and vegetables. Which of the following responses should the nurse make? Select all that apply. a. "It might be good to add bananas, as they can help with loose stools." b. "Let's make a list of the foods he is eating so we can spot any problems." c. "Did the changes begin after you started one particular food?" d. "Has he been vomiting since he started these new foods?" e. "Most babies react with a little indigestion when you start new foods."
B, C, D
To promote adherence with medication self-administration, a nurse is making recommendations for an older adult client. Which of the following instructions should the nurse include? Select all that apply. a. Adjust dosages according to daily weight b. Place pills in daily pill holders c. Ask for liquid forms in the client has difficulty swallowing pills d. Ask a relative to assist periodically E. Request child-resistant caps on medication containers
B, C, D
A nurse is performing a comprehensive physical examination of an older adult client. Which of the following interventions should the nurse use in consideration of the client's age? Select all that apply. a. Collect the data in one continuous session b. Plan to allow plenty of time for position changes c. Make sure the client has any essential sensory aids in place d. Tell the client to take her time answering questions e. Invite the client to use the bathroom before beginning the examination
B, C, D, E
A nurse is planning a presentation for a group of older adults about health promotion and disease prevention. Which of the following interventions should the nurse plan to recommend? Select all that apply. a. Human papilloma virus (HPV) immunization b. Pnumococcal immunization c. Yearly eye examination d. Periodic mental health screening e. Annual fecal occult blood test
B, C, D, E
A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse include in her counseling? Select all that apply. a. Most food poisoning is caused by a virus b. Immunocompromised inndividuals are at risk for complications from food poisoning c. Clients who are at high risk should eat or drink only pasteurized dairy products d. Healthy individuals usually recover from the illness in a few weeks e. Handling raw and fresh food separately can prevent food poisoning
B, C, E
A nurse is assessing postoperative circulation of the lower extremities for a client who had knee surgery. The nurse should include which of the following? Select all that apply. a. Range of motion b. Skin color c. Edema d. Skin lesions e. Skin temperature
B, C, E
A nurse is caring for a client who has a new diagnosis for type 2 diabetes mellitus. Which of the following nursing interventions for stress, coping, and adherence to the treatment plan should the nurse initiate at this time? Select all that apply. a. Suggest coping skills for the client to use in this situation b. Allow the client to provide input in the treatment plan c. Assist the client with time management, and address the client's priorities d. Provide extensive instructions on the client's treatment regimen e. Encourage the client in the expression of feelings and concerns
B, C, E
A nurse is caring for a client who is 24 hr postoperative following abdominal surgery. The nurse suspects the client's pain management is inadequate. Which of the following data reinforces this suspicion? Select all that apply a. The client seems easily agitated b. The client is nonadherent with coughing, deep breathing, and dangling c. The client may have pain medication every 4 to 6 hr but accepts it every 6 to 7 hr d. The client reports tenderness in his right lower leg e. The client's vital signs are heart rate 110/min, respiratory rate 20/min, temperature 37 degress C (98.6 degrees F), and blood pressure 136/80
B, C, E
A nurse is caring for a group of clients on a medical-surgical unit. Which of the following clients are at risk for body image disturbances? Select all that apply. a. 30-year-old male client following laparoscopic appendectomy b. 45-year-old female client following mastectomy c. 20-year-old female client following left above-the-knee amputation d. 65-year-old male client following cardiac catheterization e. 55-year-old male client following stroke with right-sided hemiplegia
B, C, E
A nurse is collecting data from a client who takes haloperidol to treat schizophrenia. Which of the following findings should the nurse document as extrapyramidal symptoms? Select all that apply. a. Orthostatic hypotension b. Tremors c. Acute dystonia d. Decreased level of consciousness e. Restlessness
B, C, E
A nurse is collecting data to evaluate a middle adult's psychosocial development. The nurse should expect middle adults to demonstrate which of the following developmental tasks? Select all that apply. a. Develop an acceptance of diminished strength and increased dependence on others b. Spend time focusing on improving job performance c. Welcome opportunities to be creative and productive d. Commit to finding friendships and companionship e. Become involved with community issues and activities
B, C, E
A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include in the plan of care? Select all that apply. a. Place the client in a room that has negative air pressure of at least six exchanges per hour b. Wear a mask when providing care within 3 ft of the client c. Place a surgical mask on the client if transportation to another department is unavoidable d. Use sterile gloves when handling soiled linens e. Wear a gown when performing care that might result in contamination from secretions
B, C, E
A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the five rights of delegation? Select all that apply. a. Right client b. Right supervision and evaluation c. Right direction and communication d. Right time e. Right circumstances
B, C, E
A nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include about home oxygen safety? Select all that apply. a. Family members who smoke must be at least 10 ft from the client when oxygen is in use b. Nail polish should not be used near a client who is receiving oxygen c. A "No smoking" sign should be placed on the front door d. Cotton bedding and clothing should be replaced with items made from wool e. A fire extinguisher should be readily available in the home
B, C, E
A nurse is reviewing the Centers for Disease Control and Prevention's (CDC) immunization recommendations with the parents of preschoolers. Which of the following vaccines should the nurse include in this discussion? Select all that apply a. Hameophilus influenzae type B b. Varicella c. Polio d. Hepatitis A e. Seasonal influenza
B, C, E
A nurse in a provider's office is evaluating a client who reports losing control of urine whenever she coughs, laughs, or sneezes. The client relates a history of three vaginal births, but no serious accidents or illnesses. Which of the following interventions should the nurse suggest for helping to control or eliminate the client's incontinence? Select all that apply. a. Limit total daily fluid intake b. Decrease or avoid caffeine c. Take calcium supplements d. Avoid drinking alcohol e. Use the Crede maneuver
B, D
A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? Select all that apply. a. Apply 3 to 5 mL of liquid soap to dry hands b. Wash the hands with soap and water for at least 15 seconds c. Rinse the hands with hot water d. Use a clean paper towel to turn off hand faucets e. Allow the hands to air dry after washing
B, D
During a cardiovascular examination, a nurse in a provider's office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following is the nurse attempting to auscultate? Select all that apply. a. Ventricular gallop b. Closure of the mitral valve c. Closure of the pulmonary valve d. Closure of the tricupid valve e. Murmur
B, D
A nurse is assessing an adult client's internal ear canals with an otoscope as part of a head and neck examination. Which of the following actions should the nurse take?" Select all that apply. a. Pull the the auricle down and back b. Insert the speculum slightly down and forward c. Insert the speculum 2 to 2.5 cm (0.8 to 1 in) d. Make sure the speculum does not touch the ear canal e. Use the light to visualize the tympanic membrane in a cone shape
B, D, E
A nurse is caring for a client who recently had a cerebrovascular accident and has aphasia. Which of the following interventions should the nurse use to promote communication with this client? Select all that apply. a. Increase the volume of your voice b. Make sure only one person speaks at a time c. Avoid discouraging the client by saying that you do not understand him d. Allow plenty of time for the client to respond e. Use brief sentences with simple words
B, D, E
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 collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as associated with aging? Select all that apply. a. Skin thickening b. Decreased height c. Increased saliva production d. Nail thickening e. Decreased bladder capacity
B, D, E
A nurse is reviewing the CDC's immunization recommendations with the parent of an adolescent. Which of the following recommendations should the nurse include in this discussion? Select all that apply. a. Rotavirus b. Varicella c. Herpes zoster d. Human papiloma virus e. Seasonal influenza
B, D, E
A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? Select all that apply. a. Instruct the client not to perform the Valsalva maneuver b. Apply elastic stockings c. Review laboratory values for total protein level d. Place pillows under the client's knees and lower extremities e. Assist the client to change position often
B, E
A nurse is explaining the various types of health care coverage clients might have to a group of nursing students. Which of the following health care financing mechanisms are federally funded? Select all that apply. a. Preferred provider organization (PPO) b. Medicare c. Long-term care insurance d. Exclusive provider organization (EPO) e. Medicaid
B, E
A nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? A. "I will place the client on his side" B. "I will go to the nurses' station for assistance" C. "I will administer his medications" D. "I will prepare to insert an airway"
B. "I will go to the nurses' station for assistance"
A nurse educator is teaching a module on proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that ab attendee understands the teaching? A. "My line of gravity should fall outside my base of support." B. "The lower my center of gravity, the more stability I have." C. "To broaden my base of support, I should spread my feet apart." D. "When I lift an object, I should hold it as close to my body as possible." E. "When pulling an object, I should move my front foot forward"
B. "The lower my center of gravity, the more stability I have." C. "To broaden my base of support, I should spread my feet apart." D. "When I lift an object, I should hold it as close to my body as possible."
A client says, "I've noticed how many people are out walking in my neighborhood. Is walking good for you?" What is the best response to help the client through the stages of change toward regular exercise? A) "Walking is OK. I really think running is better." B) "Yes, walking is great exercise. Do you think you could go for a 5-minute walk this next week?" C) "Yes, I want you to begin walking. Walk for 30 minutes every day and start eating more fruits and vegetables, too." D) "They probably aren't walking fast enough or far enough. You need to spend at least 45 minutes walking if you are going to do any good."
B. "Yes, walking is great exercise. Do you think you could go for a 5-minute walk this next week?" This option supports the preparation stage in which the client is beginning to consider making small changes. The other options are not good ones for this client.
For a client with a previous blood pressure of 138/74 and pulse of 64, approx. how long should the nurse take to release the bp cuff in order to obtain an accurate reading? A. 10-20 sec B. 30-45 sec C. 1-1.5 min D. 3-3.5 min
B. 30-45 sec deflation should occur at 2-3 mm Hg per second, so previous start would have been 168 (30+138) and going down at a rate of 2-3 seconds.
The nursing theory that emphasizes the delivery of nursing care for the whole person to meet the physical, emotional, intellectual, social, and spiritual needs of the client and family is: A) Rogers' theory B) Abdellah's theory C) Henderson's theory D) Nightingale's theory
B. Abdellah's theory The question describes the nursing theory developed by Fay Abdellah and others. Rogers' theory considered the individual as an energy field existing within the universe. Henderson's theory defines nursing as "assisting the individual, sick, or well, in the performance of those activities that will contribute to health, recovery, or a peaceful death." Nightingale viewed nursing as providing fresh air, light, warmth, cleanliness, quiet, and adequate nutrition.
The nursing diagnosis Hypothermia is an example of which of the following? A) Risk nursing diagnosis B) Actual nursing diagnosis C) Potential nursing diagnosis D) Wellness nursing diagnosis
B. Actual nursing diagnosis An actual nursing diagnosis describes a human response to health conditions or life processes in an individual, family, or community. The term readiness is present in a wellness nursing diagnosis. A potential nursing diagnosis is a risk for diagnosis.
The nurse questions if the dosage of a medication is unsafe for the client because of the client's weight and age. The nurse should take which of the following actions? A. Administer the medication as ordered by the prescriber B. Call the prescriber to discuss the order and the nurse's concern C. Administer the medication, but chart the nurse's concern about the dosage D. Give the client half the dosage and document accordingly
B. Call the prescriber to discuss the order and the nurse's concern Rationale: Client safety is of the utmost importance when implementing any nursing intervention. If the nurse feels that an order is unsafe or inappropriate for a client, the nurse must act as a client advocate and collaborate with the appropriate healthcare team member to determine the rationale for the order and/or modify the order as necessary. A nurse accepts accountability for his or her actions. Options 1, 3, and 4 are inappropriate and unsafe.
A client's wound is not healing and appears to be worsening with the current treatment. What is the first option the nurse should consider? A) Notifying the physician B) Calling the wound care nurse C) Consulting with another nurse D) Changing the wound care treatment
B. Calling the wound care nurse Calling in the wound care nurse as a consultant is appropriate because he or she is a specialist in the area of wound management. Professional and competent nurses recognize limitations and seek appropriate consultation. Notifying the physician may be appropriate after the nurse decides on a plan of action with the wound care nurse specialist. The nurse may need to obtain orders for special wound care products. Unless the nurse is knowledgeable in wound management, changing the wound care treatment could delay wound healing. Also, the current wound management plan might have been ordered by the physician. Another nurse most likely will not be knowledgeable about wounds, and the primary nurse would know the history of the wound management plan.
Which of the following is the most accurate information to give a nurse during change-of-shift reporting? A) Client refuses to take medications. B) Client reports sharp pain in left anterior knee. C) Client encouraged to consume more fluids. D) Client expressed concern about pending surgery.
B. Client reports sharp pain in elft anterior knee The information in option 2 represents objective data that the nurse can use as part of baseline information. "Encouraged" and "more" are vague terms. "Concern" is also vague; relating the exact concern would be more accurate. Option 1 may be true, but accurate data would also report why the client refused medication.
Interdisciplinary care plans represent: A) All nursing personnel having input in the care plan. B) Contributions of all disciplines in caring for the client. C) The client's express wishes and advance directives. D) Physicians and nurses working together to develop a plan of care.
B. Contributions of all disciplines in caring for the client Interdisciplinary care plans include the contributions of all disciplines involved in the patient's care. The client's advance directives and express wishes may be included, as well as nursing and physician input, but other involved disciplines also contribute their plans.
The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult nursing problem. The primary nurse is obligated to do which of the following? A) Implement the specialist's recommendations. B) Discuss and review advised strategies with the CNS. C) Report the recommendations to the primary physician. D) Clarify the suggestions with the client and family members.
B. Discuss and review advised strategies wtih the CNS Because the primary nurse requested the consultation, it is important that the primary nurse and the CNS communicate and discuss recommendations. The primary nurse can then accept or reject the CNS's recommendations. A consultation requires review of the recommendations but not immediate implementation. Reporting the recommendations to the physician would be appropriate after the nurse first talks with the CNS about recommended changes in the plan of care and the rationale. Only then should the primary nurse call the physician. The client and family do not have the knowledge to determine whether new strategies are appropriate or not. It is better to wait until the new plan of care is agreed upon by the primary nurse and physician before talking with the client and/or family.
When developing a nursing care plan for a client with a fractured right tibia, the nurse includes in the plan of care independent nursing interventions, including which of the following? A) Apply a cold pack to the tibia. B) Elevate the leg 5 inches above the heart. C) Perform range-of-motion movement with right leg every 4 hours. D) Administer aspirin 325 mg every 4 hours as needed.
B. Elevate the leg 5 inches above the heart Elevation of the leg does not need a physician's order. Applying a cold pack and administering medication do require a physician's order. Range-of-motion movement of the fractured tibia is inappropriate.
A theory is a set of concepts, definitions, relationships, and assumptions that: A) Formulates legislation B) Explains a phenomenon C) Measures nursing functions D) Reflects the domain of nursing practice
B. Explains a phenomenon A theory is a set of concepts, definitions, relationships, and assumptions that explains a phenomenon. Theories do not formulate legislation, measure nursing functions, or reflect any domain of nursing practice.
A client needs to learn how to administer a subcutaneous injection. The nurse knows the client is ready to learn when the client: A) Has walked 400 feet B) Expresses the importance of learning the skill C) Can see and understand the markings on the syringe D) Has the dexterity needed to prepare and inject the medication
B. Expresses the importance of learning the skill When the client can verbalize the need to learn, the client is ready to learn to read the markings on the syringe, and the nurse can assess whether the client has the dexterity to perform the injection. The ability to walk 400 feet is not a prerequisite for learning about subcutaneous injection.
11. A person's ideas, convictions, and attitudes about health and illness can be described as: A) Moral beliefs B) Health beliefs C) Holistic views D) Negative health behaviors
B. Health beliefs Health beliefs are an individual's perceptions of health or illness, which may be based on factual information or misinformation, common sense or myths, or reality or false expectations. Moral beliefs are learned behaviors that are in accordance with the principles of right or wrong. Holistic views consider the emotional and spiritual well-being of the individual. Negative health behaviors include behaviors that are typically harmful to health, such as smoking, drug or alcohol abuse, poor diet, and refusal to take appropriate medications.
Clients maintain health or enhance their health by routine exercise and proper nutrition. This is known as: A) Illness B) Health promotion C) Control of external variables D) Wellness education
B. Health promotion Health promotion activities help clients maintain and enhance their present level of health. Wellness education instructs persons on how to care for themselves in healthy ways and includes topics such as physical awareness, stress management, and self-responsibility. Illness is defined as poor condition or disease. External variables are outside factors that influence a person's health beliefs and practices. They include family practices, socioeconomic factors, and cultural background.
Different attitudes about illness cause people to react in different ways when illness does occur. Medical sociologists call the reaction to illness: A) Health belief B) Illness behavior C) Health promotion D) Illness prevention
B. Illness behavior Illness behavior is the client's reaction to illness. The other three options are models of health
A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse including in her counseling? SELECT ALL THAT APPLY A. Most food poisoning is caused by a virus B. Immunocompromised individuals are at risk for complications from food poisoning C. Clients who are at high risk should eat or drink only pasteurized dairy products D. Healthy individuals usually recover from the illness in a few weeks E. Handling raw and fresh food separately can prevent food poisoning
B. Immunocompromised individuals are at risk for complications from food poisoning C. Clients who are at high risk should eat or drink only pasteurized dairy products E. Handling raw and fresh food separately can prevent food poisoning
The nurse would place which correctly written nursing diagnostic statement into the client's care plan? A. Cancer relater to cigarette smoking B. Impaired gas exchange related to aspiration of foreign matter as evidenced by oxygen saturation of 91% C. Imbalance nutrition: more than body requirement related to overweight status D. Impaired physical mobility related to generalized weakness and pain
B. Impaired gas exchange related to aspiration of foreign matter as evidence by oxygen saturation of 91% Rationale: A nursing diagnosis consists of two parts joined by related to. The first part (the human response) names/labels the problem. The second part (related factors) includes the factors that either contribute to or are probable etiologies of the human response. Some formats include a third part to the statement for actual (not risk) diagnoses; this third part consists of the client's signs or symptoms and is joined to the statement with the label as evidenced by. This type of statement is the most complete. Option 1 is not a nursing diagnosis but is a medical diagnosis. Options 3 and 4 are vague.
A 34-year-old client had a surgical repair of an abdominal hernia in the morning. At 12 noon, the nurse records the client's vital signs on the recovery room flow sheet. What is this an example of? A) Psychomotor skill B) Indirect care measure C) Physical care technique D) Anticipating complications
B. Indirect care measures Recording vital signs is an example of indirect care. Taking vital signs is an example of a psychomotor skill. Anticipating complications is a cognitive skill that is an assessment skill. Recording vital signs is a direct care measure and not a physical care technique.
When calling a nurse consultant about a difficult client-centered problem, which of the following should the primary nurse report? A) Client's concern about the current treatment B) Length of time current treatment has been in place C) Spouse's reaction to the client's current treatment D) Physician's reluctance to change the current treatment plan
B. Length of time current treatment has been in place Reporting the length of time the current treatment has been used gives the consulting nurse facts that will influence formulation of a new plan. The other options are subjective and emotional issues or conclusions about the current treatment plan and may bias the nurse consultant's decision regarding a new treatment plan.
A nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include about home oxygen safety? SELECT ALL THAT APPLY A. Family members who smoke must be at least 10 ft from the client when oxygen is in use. B. Nail polish should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. D. Cotton bedding and clothing should be replaced with items made from wool. E. A fire extinguisher should be readily available in the home.
B. Nail polish should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. E. A fire extinguisher should be readily available in the home.
Which of the following is subjective information to be entered in the client's medical record? A) Skin warm and dry. B) Pain intensity 8 out of 10. C) Breath sounds clear to auscultation. D) Amber urine in sufficient quantities.
B. Pain intensity 8 out of 10 Pain is purely a subjective phenomenon. Although the pain intensity rating is an objective number, it depends on the client's report. The other options are objective data.
A nurse educator is discussing the facility protocol in the event of a tornado with the staff. Which of the following should the nurse include in the instructions? SELECT ALL THAT APPLY A. Open doors to clients rooms B. Place blankets over clients who are confined to beds C. Move beds away from the windows D. Draw shades and close drapes E. Instruct ambulatory clients in the hallways to return to their rooms
B. Place blankets over clients who are confined to beds C. Move beds away from the windows D. Draw shades and close drapes
The nurse who documents on the client's care plan the outcome goal "Anxiety will be relieved within 20 to 40 minutes following administration of lorazepam (Ativan)" is engaged in which step of the nursing process? A. Assessment B. Planning C. Implementation D. Evaluation
B. Planning Rationale: The planning step of the nursing process involves formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client's health problems. Outcome goals are documented on the client's care plan. Assessment data (option 1) is used to help identify a client's human response, and once a plan is established, the interventions are implemented (option 3) and evaluated (option 4).
10. A nurse teaches the importance of folic acid intake to a group of pregnant women. This is considered which level of preventive care? A) Illness behavior B) Primary prevention C) Tertiary prevention D) Secondary prevention
B. Primary prevention Primary prevention is considered true prevention. It aims at maintaining physical and emotional health in an already healthy individual.Primary prevention is considered true prevention. It aims at maintaining physical and emotional health in an already healthy individual.
A parish nurse for a Catholic church provides a free blood pressure screening the first Sunday of every month. This is what level of prevention? A) Tertiary prevention B) Primary prevention C) Secondary prevention D) Quaternary prevention
B. Primary prevention Primary prevention is true prevention that precedes disease and is aimed at clients considered physically and emotionally healthy. Secondary prevention involves individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Tertiary prevention occurs when a defect or disability is permanent and irreversible, and the aim is to reduce negative impacts and complications. Quaternary prevention is not a recognized term.
After establishing a nursing diagnosis of Acute pain, the nurse develops which of the following appropriate client-centered goals? A) Determine effect of pain intensity on client function. B) Reduce pain intensity to the level of a client rating of 3 or below during the client's hospital stay. C) Encourage client to implement guided imagery when pain begins. D) Administer analgesic 30 minutes before physical therapy treatment.
B. Reduce pain intensity to the level of a client rating of 3 or below during the client's hopsital stay
The nurse makes the following entry on the client's care plan: "Goal not met. Client refuses to ambulate, stating, 'I am too afraid I will fall.' " The nurse should take which of the following actions? A. Notify the physician B. Reassign the client to another nurse C. Reexamine the nursing orders D. Write a new nursing diagnosis
B. Reexamine the nursing orders Rationale: The plan needs to be reassessed whenever goals are not met. Nursing interventions should be examined to ensure the best interventions were selected to assist the client achieve the goal. The goal may be appropriate, but the client may need more time to achieve the desired outcome. The manner in which the nursing interventions were implemented may have interfered with achieving the outcome.
A nurse provides counseling to a family in spiritual distress caused by the recent, but expected, death of a family member when the nurse implements which of the following interventions? A) Praying with the family B) Reminiscing with the family C) Arranging for the chaplain to visit the family D) Obtaining a consult with a psychiatric clinical nurse specialist
B. Reminiscing with the family Reminiscing is an active intervention that allows family members to remember the deceased in a positive way. One expects spiritual distress in the acute stage of loss. Praying with the family and arranging for a chaplain's visit may be appropriate interventions, but they are not counseling.
The nurse is teaching a parenting class for a group of pregnant adolescents and has given the adolescents baby dolls to bathe and talk to. This is an example of: A) An analogy B) Role playing C) A demonstration D) A return demonstration
B. Role playing Role playing involves rehearsing a desired behavior. In demonstration the nurse shows the client what to do, whereas in return demonstration the learner practices the skill to show that it has been learned. An analogy is a means of translating complex language or ideas into words or concepts that the client understands.
When the client resists taking a liquid medication that is essential to treatment, the nurse demonstrates critical thinking by doing which of the following first? A. Omitting this dose of medication and waiting until the client is more cooperative B. Suggesting the medication can be diluted in a beverage C. Asking the nurse manager about how to approach the situation D. Notifying the physician inability to give the client this medication
B. Suggesting the medication can be diluted in a beverage Rationale: Diluting the medication in a beverage may make the medication more palatable. Using critical thinking skills, the nurse should try to problem-solve in a situation such as this before asking for the assistance of the nurse manager. Suggesting an alternative method of taking the medication (provided that there are no contraindications to diluting the medication) should improve the likelihood of the client taking the medication.
The nurse is measuring the client's urine output and straining the urine to assess for stones. Which of the following should the nurse record as objective data? A. The client reports abdominal pain B. The client's urine output was 450 mL C. The client states, "I didn't see any stones in my urine." D. The client states, "I feel like I have passed a stone."
B. The client's urine output was 450 mL. Rationale: Objective data is measurable data that can be seen, heard, or verified by the nurse. The objective data is the measurement of the urine output. A client's statements and reports of symptoms are documented as subjective data, such as the data found in options 1, 3, and 4.
The nurse should plan to teach a client about the importance of exercise: A) When there are visitors in the room B) When the client's pain medications have taken effect C) Just before lunch, when the client is most awake and alert D) When the client is talking about current stressors in his or her life
B. When the client's pain medications have taken effect It is difficult for a client to learn when the client is in pain. Pain medications should be administered and the client taught while the client is alert but pain free. A quiet time should be selected when there are no or few distractions; the nurse should avoid times when visitors are present or when the client is discussing other stressors. The second best time to teach is when the client is most awake and alert, providing that all pain issues have been addressed.
know the position for a patient that had bone marrow taken out
BM aspiration site: iliac crest
16.A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented? A. Continue gabapentin. B. Discontinue ibuprofen. C. Add aspirin to the protocol. D. Add oral methadone to the protocol.
Based on the WHO pain relief ladder, adjunct medications, such as gabapentin (Neurontin), an antiseizure medication, may be used at any step for anxiety and pain management, so (A) should be implemented. Nonopiod analgesics, such as ibuprofen (A) and aspirin (C) are Step 1 drugs. Step 2 and 3 include opioid narcotics (D), and to maintain freedom from pain, drugs should be given around the clock rather than by the client s PRN requests. Correct Answer: A
47.What client statement indicates to the nurse that the client requires assistance with bathing? A. I wasn't able to pack a bag before I left for the hospital. B. I don't understand why I'm so weak and tired. C. I only bathe every other day. D. I left my eyeglasses at home.
Bathing often makes a client feel weak, and if a client is already feeling weak (B), assistance is required during the bathing process to ensure the client's safety. (A and C) do not pose safety issues. Although (D) may pose a safety issue, further assessment is needed to determine if this in fact poses a safety issue for the client. Correct Answer: B
An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide?
Be sure to have a complete physical examination before beginning your planned exercise program.
After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A. Determine the etiology of the problem. B. Prioritize nursing care interventions. C. Plan appropriate interventions. D. Collaborate with the client to set goals.
Before planning care, the nurse should determine the etiology, or cause, of the problem (A), because this will help determine (B, C, and D). Correct Answer: A
13.A client with Raynaud's disease asks the nurse about using biofeedback for self-management of symptoms. What response is best for the nurse to provide? A. The responses to biofeedback have not been well established and may be a waste of time and money. B. Biofeedback requires extensive training to retrain voluntary muscles, not involuntary responses. C. Although biofeedback is easily learned, it is mostly often used to manage exacerbation of symptoms. D. Biofeedback allows the client to control involuntary responses to promote peripheral vasodilation.
Biofeedback involves the use of various monitoring devices that help people become more aware and able to control their own physiologic responses, such as heart rate, body temperature, muscle tension, and brain waves. (D) is an accurate statement concerning its use for clients with Raynaud's disease. (A, B, and C) do not provide correct information about biofeedback. Correct Answer: D
A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs?
Blood transfusions are forbidden.
Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A. Aspirating gastric contents to assure a pH value of 4 or less. B. Hearing air pass in the stomach after injecting air into the tubing. C. Examining a chest x-ray obtained after the tubing was inserted. D. Checking the remaining length of tubing to ensure that the correct length was inserted.
Both (A and B) are methods used to determine proper placement of the NG tubing. However, the best indicator that the tubing is properly placed is (C). (D) is not an indicator of proper placement. Correct Answer: C
Beta blocker OD in pediatric client?
Bradycardia
1.What is the rationale for using the nursing process in planning care for clients? A. As a scientific process to identify nursing diagnoses of a clients' healthcare problems. B. To establish nursing theory that incorporates the biopsychosocial nature of humans. C. As a tool to organize thinking and clinical decision making about clients' healthcare needs. D. To promote the management of client care in collaboration with other healthcare professionals.
C (The nursing process is a problem-solving approach that provides an organized, systematic, decision making process to effectively address the client's needs and problems. The nursing process includes an organized framework using knowledge, judgments, and actions by the nurse as the client's plan of care is determined, and encompasses assessment, analysis, planning, implementation, and evaluation of client care (C). (A, B, and D) do not support the basis for using the nursing process. Correct Answer: C)
The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to administer? A) ½ tablet. B) 1 tablet. C) 1½ tablets. D) 2 tablets.
C) 1½ tablets
Which response by a client with a nursing diagnosis of Spiritual distress, indicates to the nurse that a desired outcome measure has been met? A) Expresses concern about the meaning and importance of life B) Remains angry at God for the continuation of the illness. C) Accepts that punishment from God is not related to illness. D) Refuses to participate in religious rituals that have no meaning.
C) Accepts that punishment from God is not related to illness Acceptance that she is not being punished by God indicates a desired outcome (C) for some degree of resolution of spiritual distress. (A, B, and D) do not support the concept of grief, loss, and cultural/spiritual acceptance.
During a physical assessment, a female client begins to cry. Which action is best for the nurse to take? A) Request another nurse to complete the physical assessment. B) Ask the client to stop crying and tell the nurse what is wrong. C) Acknowledge the client's distress and tell her it is all right to cry. D) Leave the room so that the client can be alone to cry in private.
C) Acknowledge the client's distress and tell her it is all right to cry Acknowledging the client's distress and giving the client the opportunity to verbalize her distress (C) is a supportive response. (A, B, and D) are not supportive and do not facilitate the client's expression of feelings
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? A) Record the coughing incident. No further action is required at this time. B) Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. C) After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. D) Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.
C) After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking any other action (C). (A and B) are not indicated. The auscultating method (D) has been found to be unreliable for small-bore feeding tubes.
12. For which airborne disease(s) would the nurse be required to use gloves, respiratory devices, and gown when in close contact with the client? A) Herpes simplex, scabies B) Viral pneumonia, atelectasis C) Chickenpox, pulmonary tuberculosis D) Multidrug-resistant respiratory syncytial virus
C) Chickenpox, pulmonary tuberculosis Airborne precautions are required for chickenpox and tuberculosis, because in these diseases small particles float in the air and a barrier is required to prevent contamination of the nurse. A respiratory protection device is form-fitted to the face to prevent the escape of air around the seal. Gloves and gown are also worn to prevent contamination and transport of infective particles to other clients. For viral pneumonia a regular mask is used as a barrier because the particles do not float in the air and are more likely to be found on surfaces unless coughing or spitting is occurring. Atelectasis is the collapse of alveoli, and airborne precautions are not needed. Herpes and scabies are spread by contact, and gloves and gown would be necessary; masks would not be needed. For multidrug-resistant respiratory syncytial virus the protection of the client would be as important as preventing the spread of these disorders. Therefore, gown, gloves, and mask would be used as in reverse isolation to prevent cross contamination of the client.
During the nurse's assessment of a 56-year-old man, he reports increased alcohol consumption because of stress at work. One of the expected outcomes for this client will be to: A) Decrease stress in his life. B) Teach him ways to promote sleep. C) Decrease his alcohol intake during times of stress. D) Provide the client with information about stress management classes.
C) Decrease his alcohol intake during times of stress. Resources for stress management and sleep promotion can help accomplish reduced alcohol intake during times of stress in the client's life. Management of stress is the expectation, but decreasing stress may not be possible.
During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? A) Adequate venous blood flow to the lower extremities. B) Estimated amount of body fat by an underarm skinfold. C) Degree of flexion and extension of the client's knee joint. D) Change in the circumference of the joint in centimeters
C) Degree of flexion and extension of the client's knee joint The goniometer is a two-piece ruler that is jointed in the middle with a protractor-type measuring device that is placed over a joint as the individual extends or flexes the joint to measure the degrees of flexion and extension on the protractor (C). A doppler is used to measure blood flow (A). Calipers are used to measure body fat (B). A tape measure is used to measure circumference of body parts (D).
A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 normal saline (NS) with potassium chloride (KCl) 20 mEq at 83 ml/hour. The client's eight-hour urine output is 400 ml, blood urea nitrogen (BUN) is 15 mg/dl, lungs are clear bilaterally, serum glucose is 120 mg/dl, and the serum potassium is 3.7 mEq/L. Which action is most important for the nurse to implement? A) Notify healthcare provider and request to change the IV infusion to hypertonic D10W. B) Decrease in the infusion rate of the current IV and report to the healthcare provider. C) Document in the medical record that these normal findings are expected outcomes. D) Obtain potassium chloride 20 mEq in anticipation of a prescription to add to present IV.
C) Document in the medical record that these normal findings are expected outcomes The results are all within normal range.(C) No changes are needed. (A,B, and D)
The nurse discovers an electrical fire in a client's room. The nurse's first action would be to: A) Activate the fire alarm. B) Confine the fire by closing all doors and windows. C) Evacuate any clients or visitors in immediate danger. D) Extinguish the fire by using the nearest fire extinguisher.
C) Evacuate any clients or visitors in immediate danger. The nurse's first step when a fire is discovered is to evacuate any clients or visitors in immediate danger. Then the nurse should activate the fire alarm, confine the fire, and then extinguish it.
Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A) Aspirating gastric contents to assure a pH value of 4 or less. B) Hearing air pass in the stomach after injecting air into the tubing. C) Examining a chest x-ray obtained after the tubing was inserted. D) Checking the remaining length of tubing to ensure that the correct length was inserted.
C) Examining a chest x-ray obtained after the tubing was inserted Both (A and B) are methods used to determine proper placement of the NG tubing. However, the best indicator that the tubing is properly placed is (C). (D) is not an indicator of proper placement
Before the nurse washes the hands when leaving an isolation room, what is the last thing that is removed? A) Mask B) Gown C) Goggles D) Head cover
C) Goggles Goggles are the least contaminated item and the last to be removed before hand washing. The gown and gloves have been removed first. Head covers are usually not worn in isolation rooms as a barrier. The mask is considered contaminated, and it should be untied and discarded after the gown is removed to minimize contamination from the gown or gloves.
To remove a glove that is contaminated, what should the nurse do first? A) Rinse the glove before removing it to minimize contamination. B) Pull the glove off the back of the hand until it slides off the entire hand and discard it. C) Grasp the outside of the cuff or palm of the glove and pull it away from the hand without touching the wrist or fingers. D) Put the thumb inside the wrist to slide the glove over the hand with minimal touching of the hand by the other gloved hand.
C) Grasp the outside of the cuff or palm of the glove and pull it away from the hand without touching the wrist or fingers. When the outside of the cuff is grasped with the contaminated gloved hand, then dirty to dirty remains intact. Pulling the glove away from the hand entirely without touching the wrist or fingers further minimizes the contamination by the gloved hand. If the nurse puts the gloved thumb inside the glove, the nurse has contaminated the bare hand with a contaminated thumb. Pulling the glove off by holding it at the back sounds good and could minimize contamination, but it is very difficulty to remove a glove this way without the risk of tearing the glove and creating contamination through the tear. If excessive secretions are present on gloves, then a towel or the drape could be used to wipe off excessive secretions before an attempt is made to remove the gloves.
A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record? A) Healthcare provider notified of failure to collect specimens for prescribed blood studies. B) Blood specimens not collected because client no longer wants blood tests performed. C) Healthcare provider notified of client's refusal to have blood specimens collected for testing. D) Client irritable, uncooperative, and refuses to have blood collected. Healthcare provider notified
C) Healthcare provider notified of client's refusal to have blood specimens collected for testing When a client refuses a treatment, the exact words of the client regarding the client's refusal of care should be documented in a narrative format (C). (A, B, and D) do not address the concepts of informatics and legal issues
The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A) If I exercise at least two times weekly for one hour, I will lower my cholesterol. B) I need to avoid eating proteins, including red meat. C) I will limit my intake of beef to 4 ounces per week. D) My blood level of low density lipoproteins needs to increase.
C) I will limit my intake of beef to 4 ounces per week Limiting saturated fat from animal food sources to no more than 4 ounces per week (C) is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week (A). Red meat and all proteins do not need to be eliminated (B) to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions (2-ounce servings). The low density lipoproteins (D) need to decrease rather than increase
The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A) Infuse normal saline at a keep vein open rate. B) Discontinue the IV and flush the port with heparin. C) Infuse 10 percent dextrose and water at 54 ml/hr D) Obtain a stat blood glucose level and notify the healthcare provider.
C) Infuse 10 percent dextrose and water at 54 ml/hr TPN is discontinued gradually to allow the client to adjust to decreased levels of glucose. Administering 10% dextrose in water at the prescribed rate (C) will keep the client from experiencing hypoglycemia until the next TPN solution is available. The client could experience a hypoglycemic reaction if the current level of glucose (A) is not maintained or if the TPN is discontinued abruptly (B). There is no reason to obtain a stat blood glucose level (D) and the healthcare provider cannot do anything about this situation
When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? A) Complimentary healing practices interfere with the efficacy of the medical model of treatment. B) Conventional medications are likely to interact with folk remedies and cause adverse effects. C) Many complimentary healing practices can be used in conjunction with conventional practices. D) Conventional medical practices will ultimately replace the use of complimentary healing practices.
C) Many complimentary healing practices can be used in conjunction with conventional practices Conventional approaches to health care can be depersonalizing and often fail to take into consideration all aspects of an individual, including body, mind, and spirit. Often complimentary healing practices can be used in conjunction with conventional medical practices (C), rather than interfering (A) with conventional practices, causing adverse effects (B), or replacing conventional medical care (D).
14. The nurse is setting up a sterile field for the physician. Which of the following statements concerning a sterile field is correct? A) The sides of the drape over the table are still sterile until they are touched. B) Reaching over the field is not a source of contamination if the nurse has on a clean gown and gloves. C) One inch around the border should be considered to be the barrier between the sterile field and under the table. D) A liquid spill onto the sterile field is a source of contamination from the table below the drape, even if the barrier is waterproof.
C) One inch around the border should be considered to be the barrier between the sterile field and under the table. A 1-inch margin is considered unsterile and is the barrier spacing between the sterile field in the center of the drape and the edge of the drape. Liquids spilled on a waterproof drape will not absorb from or be contaminated from the surface beneath. Although such a situation could be messy, bacteria would not cross from the unsterile to the sterile side. The edge of the table and the 1-inch border create the edge of the sterile field. Anything below the edge, including the side of the drape, becomes unsterile. Reaching over a sterile field is always a source of contamination and should not be done.
The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? A) Remain calm with the client and record abnormal results in the chart. B) Notify the medication nurse immediately if the pulse or blood pressure is low. C) Report the results of the vital signs to the nurse. D) Reassure the client that the vital signs are normal.
C) Report the results of the vital signs to the nurse. Interpretation of vital signs is the responsibility of the nurse, so the UAP should report vital sign measurements to the nurse (C). (A, B, and D) require the UAP to interpret the vital signs, which is beyond the scope of the UAP's authority
An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? A) Position the client on the right side of the bed in reverse Trendelenburg. B) Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C) Reposition in a Sim's position with the client's weight on the anterior ilium. D) Raise the side rails on both sides of the bed and elevate the bed to waist level.
C) Reposition in a Sim's position with the client's weight on the anterior ilium The left sided Sims' position allows the enema solution to follow the anatomical course of the intestines and allows the best overall results, so the UAP should reposition the client in the Sims' position, which distributes the client's weight to the anterior ilium (C). (A) is inaccurate. (B and D) should be implemented once the client is positioned
The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? A) Tossed salad, low-sodium dressing, bacon and tomato sandwich. B) New England clam chowder, no-salt crackers, fresh fruit salad. C) Skim milk, turkey salad, roll, and vanilla ice cream. D) Macaroni and cheese, diet Coke, a slice of cherry pie.
C) Skim milk, turkey salad, roll, and vanilla ice cream Skim milk, turkey, bread, and ice cream (C), while containing some sodium, are considered low-sodium foods. Bacon (A), canned soups (B), especially those with seafood, hard cheeses, macaroni, and most diet drinks (D) are very high in sodium
What is the single most effective method by which the nurse can break the chain of infection? A) Give all clients antibiotics. B) Wear gloves when caring for all clients. C) Wash hands between procedures and clients. D) Make sure housekeeping staff are using the right chemicals.
C) Wash hands between procedures and clients. Adequate hand washing will remove bacteria and wastes or contaminates to minimize cross contamination between clients. Use of alcohol-based waterless antiseptics between clients is also effective if the guidelines for using these cleansers are followed. Giving all clients antibiotics is impractical and is a source of new superinfections when persons who do not need antibiotics are given them and then the bacteria mutate to become resistant to older drugs. It would be both unethical and costly to try to control infections by treating everyone in the facility. Although wearing gloves to perform procedures that carry the risk of direct contact with contaminated material is a correct method of bacterial control, wearing gloves at all times is impractical, expensive, and unrealistic. Housekeeping staff are trained to use the correct agents for decontamination and disinfection of all surfaces that place clients at risk.
A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client A) asks relevant questions regarding the dressing change. B) states he will be able to complete the wound care regimen. C) demonstrates the wound care procedure correctly. D) has all the necessary supplies for wound care.
C) demonstrates the wound care procedure correctly A return demonstration of a procedure (C) provides an objective assessment of the client's ability to perform a task, while (A and B) are subjective measures. (D) is important, but is less of a priority prior to discharge than the nurse's assessment of the client's ability to complete the wound care
A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? Select all that apply a. Writing a prescription for morphine sulfate as need for pain b. Inserting a nasogastric (NG) tube to relieve gastric distention c. Showing a client how to use progressive muscle relaxation d. Performing a daily bath after the evening meal e. Repositioning a client every 2 hr to reduce pressure ulcer risk
C, D, E
A nurse is assisting a newly licensed nurse with postmortem care of a client. The family wishes to view the body. Which of the following statements by the newly licensed nurse indicates an understanding of the procedure? Select all that apply. a. "I will remove the dentures from the body." b. "I will make sure the body is lying completely flat." c. "I will apply fresh linens and place a clean gown on the body." d. "I will remove all equipment from the bedside." e. "I will dim the lights in the room."
C, D, E
A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? Select all that apply. a. Place a belt restraint on the client when he is sitting on the bedside commode b. Keep the bed in its lowest position with all side rails up c. Make sure that the client's call light is within reach d. Provide the client with nonskid footwear e. Complete a fall-risk ssessment
C, D, E
A nurse is caring for a client who is concerned about his impending discharge to home with a new colostomy because he is an avid swimmer. Which of the following statement should the nurse make? Select all that apply. a. "You will do great? You just have to get used to it." b. "Why are you worried about going home?" c. "Your daily routines will be different when you get home." d. "Tell me about your support system you'll have after you leave the hospital." e. "Let me tell you about a friend of mine with a colostomy who also enjoys swimming."
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. Hyperthemia c. Tachycardia d. Syncope e. Decreased skin turgor
C, D, E
A nurse is preparing to administer medications to a preschooler. Which of the following strategies should the nurse implement to increase the child's cooperation in taking medications? Select all that apply. a. Reassure the child an injection will not hurt b. Mix oral medications in a large glass of milk c. Offer the child choices when possible d. Have the parent bring in a favorite toy from home e. Engage the child in pretend play with a toy medical kit
C, D, E
A nurse is providing teaching for an older adult client who has lost 4.5 kg (9.9 lb) since his last admission 6 months ago. Which of the following instructions should the nurse include in the teaching? Select all that apply. a. "Eat three large meals a day." b. "Eat your meals in front of the television." c. "Eat foods that are easy to eat, such as finger foods." d. "Invite family members to eat meals with you." e. "Exercise every day to increase appedtite
C, D, E
A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the follow objects can the nurse touch without breaching sterile technique? Select all that apply. a. A bottle containing sterile solution b. The edge of the sterile drape at the base of the sterile field c. The inner wrapping of an item on the sterile field d. An irrigation syringe on the sterile field e. One gloved hand with the other gloved hand
C, D, E
A nurse in a provider's office is preparing to assess a young adult male client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? Select all that apply. a. Concave thoracic spine posteriorly b. Exaggerated lumbar curvature c. Concave lumbar spine posteriorly d. Exaggerated thoracic curvature e. Muscles slightly larger on his dominant side
C, E
A nurse in a provider's office is preparing to auscultate and percuss a client's thorax as part of a comprehensive physical examination. Which of the following findings should the nurse expect? Select all that apply. a. Rhonchi b. Crackles c. Resonance d. Tactile fremitis e. Bronchovesicular sounds
C, E
A nurse in a provider's office is preparing to test a client's cranial nerve function. Which of the following directions should she include when testing cranial nerve V? Select all that apply. a. "Close your eyes." b. "Tell me that you can taste." c. "Clench your teeth." d. "Raise your eyebrows." e. "Tell me when you feel a touch."
C, E
During the planning phase of the nursing process, the nurse along with the client decides which of the following? (Select all that apply.) A) Interventions B) Nursing diagnosis C) Expected outcomes D) Client-centered goals E) Nurse-centered priorities
C, and D Expected outcomes and goals are the main components of the planning phase of the nursing process. The nurse determines these from the assessment. The client should be the focus of the planning stage. Interventions are initially determined by the nurse.
3. Based on the transtheoretical model of change, what is the most appropriate response to the following client statement: "Me, exercise? I haven't done that since Junior High gym class and I hated it then!" A) "That's fine. Exercise is bad for you anyway." B) "OK. I want you to walk 3 miles four times a week and I'll see you in 1 month." C) "I understand. Can you think of one reason why being more active would be helpful for you?" D) "I'd like you to ride your bike three times this week and eat at least four fruits and vegetables every day."
C. "I understand. Can you think of one reason why being mroe active would be helpful for you?" The transtheoretical model of change describes a series of changes that clients move through, starting with precontemplation and ending with maintenance. The first stage for this client would be to validate the client's opinion and move to the first part of precontemplation. The other options are later steps in the model.
Which of the following statements is the World Health Organization's definition of health? A) "Complete freedom from disease" B) "Mental, social, and spiritual well-being" C) "State of complete physical, mental, and social well-being, not merely the absence of disease" D) "A state of being that people define in relation to their own values, personality, and lifestyle"
C. "State of complete physical, mental, and social well-being, not merely the absence of disease" The World Health Organization defines health as a "state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity." There are several definitions of health. Health is a state of being that people define in relation to their own values, personality, and lifestyle. Health and illness must be defined in terms of the individual. Health can include conditions previously considered to be illness. Pender, Murdaugh, and Parsons note that views of health include mental, social, and spiritual well-being. Pender notes that not all people who are free of disease are equally healthy.
Which of the following is an open-ended question the nurse might use when interviewing a client? A) "Do you have any concerns right now?" B) "Is your family worried about your being in the hospital?" C) "What do you mean when you say, 'I don't feel quite right'?" D) "How many times do you get up to go to the bathroom at night?"
C. "What do you mean when you say, 'I don't feel quite right'?" The way the nurse asks question 3 allows the client to respond completely and with more than a one-word answer. The other options allow the client to respond with one word and make it unlikely that the client will give additional information.
The nurse is assessing the urinary history of a middle-aged married woman. The nurse asks her if she gets up at night. She replies, "Yes." What other question should the nurse ask? A) "How many times do you get up at night?" B) "How long have you been getting up at night?" C) "Why do you get up at night?" D) "How easily do you go back to sleep after you get up?"
C. "Why do you get up at night?" Perhaps it is the client's husband who is getting up in the middle of the night because of a prostate problem, and this is why she is awakened. The nurse should not assume nocturia without further assessment questions.
A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the priority? A. A client who received crush injuries to the chest and abdomen and is expected to die B. A client who has a 4-inch laceration to the head C. A client who has partial-thickness burns to his face, neck, and chest D. A client who has a fractured fibula and tibia
C. A client who has partial-thickness burns to his face, neck, and chest
A nurse on a medical-surgical unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge stable clients to make beds available for injury victims. Which of the following clients should the nurse recommend for discharge? SELECT ALL THAT APPLY A. A client who is dehydrated and receiving IV fluid and electrolytes B. A client who has a nasogastric tube to treat a small bowel obstruction C. A client who is scheduled for a elective surgery D. A client who has chronic hypertension and blood pressure 135/85 mmHg E. A client who has acute appendicitis and is scheduled for an appendectomy
C. A client who is scheduled for a elective surgery D. A client who has chronic hypertension and blood pressure 135/85 mmHg
nursing diagnosis is: A) The diagnosis and treatment of human responses to health and illness B) The advancement of the development, testing, and refinement of a common nursing language C) A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes D) The identification of a disease condition based on a specific evaluation of physical signs, symptoms, the client's medical history, and the results of diagnostic tests
C. A clinical judgment about individual, family, or community responses toa ctual and potential health problems or life processes A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes. It is not a disease condition or medical diagnosis, or the diagnosis and treatment of human responses to health and illness. Nursing diagnoses are not a development or refinement in nursing language.
A nurse refers to a client's postsurgical written plan of care, noting that the client has a drainage device collecting wound drainage. The surgeon is to be notified when drainage in the device exceeds 100 ml for the day. The nurse carefully notes the amount of drainage currently in the device. This is an example of: A. Planning B. Evaluation C. Assessment D. Intervention
C. Assessment Assessment is the process of observing and collecting data. Planning is the step in which the diagnosis is analyzed for problem resolution. Intervention consists of the steps actually taken after planning. Evaluation measures the effectiveness of the plan.
An 85-year-old client has had a stroke resulting in right sided facial drooping, difficulty swelling and is unable to move self or maintain position unaided. The nurse determines that which of the follow sites is appropriate for taking temp A. Oral, Tympanic, Rectal B. Rectal, Tympanic, Axillary C. Axillary, Typmpanic, Temporal D. Axillary, Temporal, Oral
C. Axillary, Typmpanic, Temporal Feedback Ok - oral + stroke + facial dropping = no. Rectal would work but that's wayyy to much extra work when you have other methods.
An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? A. Irrigate the affected area with running water B. Was the affected area with antibacterial soap C. Brush the chemical off the skin and clothing D. Leave the clothing in place until emergency personnel arrive
C. Brush the chemical off the skin and clothing
Which of the following outcome goals has the nurse designed correctly for the postoperative client's plan of care? Select all that apply. A. Client will state pain is less than or equal to 3 on zero to ten pain scale B. Client will have no pain C. Client will state pain is less than or equal to a 3 on a 0-10 pain scale within 24 hours D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by the time of discharge E. Client will be medicated every 4 hours by the nurse
C. Client will state pain is less than or equal to a 3 on a 0-10 pain scale within 24 hours D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by the time of discharge Rationale: An outcome goal should be SMART: specific, measurable, appropriate, realistic, and timely. Options 3 and 4 are SMART goals. Options 1 and 2 have no timeframe to achieve the goal and are therefore incomplete. Option 2 is also unrealistic; the nurse cannot expect a postoperative client to be pain free. Option 5 is not a client goal.
What type of interview technique is the nurse using when the nurse asks the question, "Do you have pain or cramping?" A) Active listening B) Open-ended questioning C) Closed-ended questioning D) Problem-oriented questioning
C. Closed-ended question The example is a closed-ended question which the client can answer with a one-word reply. Open-ended questions allow the client to answer with more information. The other options are not correct.
A learning objective for a client taking digoxin (Lanoxin) is to correctly take a radial pulse for 1 minute before medication administration. The learning objective has been achieved when the client: A) States, "I understand." B) States, "Just place two fingers at the thumb side of the wrist." C) Demonstrates correct finger placement and counts the beats correctly D) Demonstrates by placing two fingers at the inner antecubital space and counts the beats for 60 seconds
C. Demonstrates correct finger placement and counts the beats correctly Direct observation is a means of evaluating whether a learning objective has been achieved. In option 3 the client demonstrated radial pulse taking correctly. Option 1 provides no way of measuring if the client was able to correctly take a radial pulse. Option 2 does not indicate if the client was able to count the number of beats for 1 minute. In option 4 the fingers were placed in the antecubital space rather than over the radial artery. The client demonstrated incorrect placement.
Each science has a domain, which is the perspective of the discipline. This domain: A) Represents the recipients of the benefits of the science or discipline B) Is a model that explains the linkage of science, philosophy, and theory that is accepted and applied by the discipline C) Describes the subject, central concepts, values and beliefs, phenomena of interest, and central problems of the discipline D) Is a dynamic state of being in which the developmental and behavioral potential of the individual is realized to the fullest
C. Describes the subject, central concepts, values and beliefs, phenomena of interest, and central problems of the discipline The domain contains the subject, central concepts, values and beliefs, phenomena of interest, and the central problems of the discipline. A paradigm is a model that explains the linkage of science, philosophy and theory that is accepted and applied by the discipline.
The school nurse is about to teach a freshman-level health class on nutrition. To achieve the best learning outcomes, the nurse: A) Provides information using a lecture format B) Uses simple words to promote understanding C) Develops topics for discussion that require problem solving D) Completes an extensive literature search focusing on eating disorders
C. Develops topics for discussion that require problem solving The use of problem solving helps adolescents to achieve learning outcomes. Providing information in a lecture format and using simple words would probably not be successful with this age group. Literature searches are not appropriate teaching for this age group.
"Unhappy and worried about health" is not a scientifically-based nursing diagnosis, and it can lead to error in: A) Data collection B) Date clustering C) Diagnostic label D) Medical diagnosis
C. Diagnostic label The diagnostic label is the name of the nursing diagnosis as approved by the North American Nursing Diagnosis Association (NANDA) International. The question does not discuss data collection, medical diagnosis, or data clustering.
Which of the following nursing interventions is written correctly? A) Change dressing once a shift. B) Perform neurovascular checks. C) Elevate head of bed 30 degrees before meals. D) Apply continuous passive motion machine during day.
C. Elevate head of bed 30 degrees before meals Option 3 is specific—it indicates what to do and when
A nurse is caring for a client who reports pain with internal rotation of her right shoulder. The nurse should identify that this discomfort can affect the client's ability to perform which of the following activities? A. Mopping her floors B. Brushing the back of her hair C. Fastening her bra behind her D. Reaching into a cabinet above her sink
C. Fastening her bra behind her
In developing a plan of care for a client with chronic hypertension, which nursing activity would be most important? A. Set incremental goals for blood pressure reduction B. Instruct the client to make dietary changes by reducing sodium intake C. Include the client and family when setting goals and formulating the plan of care D. Assess past compliance to medication regimens
C. Include the client and family when setting goals and formulating the plan of care Rationale: In developing a plan of care, nurses engage in a partnership with the client and family. Nurses do not plan care for clients; instead they plan care with clients and families. Assessment (option 4), goal setting (option 1), and interventions (option 2) will be most accurate and effective when carried out in partnership with the client and family. The other options represent other actions to take, but they will have less overall effectiveness if the client and family are not part of the plan.
17. The nursing process is an example of an open system. An open system: A) Is universal and dynamic B) Represents a relationship between two concepts C) Interacts with the environment by exchanging information D) Is a process through which information is returned to the system
C. Interacts with the environment by exchanging information An open system is defined as a system that interacts with the environment, exchanging information between the system and the environment.
The nurse asks a client how she feels about impending surgery for breast cancer. Before initiating the discussion the nurse reviewed information about loss and grief in addition to therapeutic communication principles. The critical thinking component involved in the nurse's review of the literature is: A) Experience B) Problem solving C) Knowledge application D) Clinical decision making
C. Knowledge application The nurse sought appropriate information to be able to communicate more knowledgeably with the client. Experience is acquired through clinical learning situations. Problem solving is a series of steps to resolve a problem. Clinical decision making is a process in which critical thinking steps are followed for problem resolution.
A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? SELECT ALL THAT APPLY A. Place a belt restraint on the client when he is sitting on the bedside commode B. Keep the bed in its lowest position with all side rails up C. Make sure that the clients call light is within reach call light. D. Provide the client with nonskid footwear E. Complete a fall-risk assessment
C. Make sure that the clients call light is within reach call light. D. Provide the client with nonskid footwear E. Complete a fall-risk assessment
A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority? A. Extinguish the fire B. Activate the fire alarm C. Move clients who are nearby D. Close all open doors on the unit
C. Move clients who are nearby
Which of the following models of health or illness defines health as a positive, dynamic state, not merely the absence of disease? A) Maslow's hierarchy of needs B) Rosenstoch's health belief model C) Pender's health promotion model D) The holistic health model of nursing
C. Pender's health promotion model Pender's health promotion model was developed to be a "complementary counterpart to models of health protection." This model defines health as a positive, dynamic state, not merely the absence of disease. Maslow's hierarchy of needs defines what is necessary for human survival and health, such as food, water, safety, and love. Rosenstoch's health belief model addresses the relationship between a person's belief and behaviors. It predicts how clients will behave in relation to their health and how they will comply with their health regimen. The holistic health model creates conditions that promote optimal health.
During the day the nurse spends time instructing a client in how to self-administer insulin. After discussing the technique and demonstrating an injection, the nurse asks the client to try it. After the client makes two attempts it is clear that the client does not understand how to prepare the correct dose. The nurse discusses the situation with the charge nurse and asks for suggestions. This is an example of: A. Reflection B. Risk taking C. Problem solving D. Client assessment
C. Problem Solving This is an example of problem solving because the nurse is taking a problem to a supervisor for help in finding a different approach. Reflection is the process of purposefully thinking back and recalling a situation to discover its purpose or meaning. Risk taking involves trying a different approach. Client assessment is the first step in the process of instruction.
A client recently diagnosed with cervical cancer is going home after undergoing surgery. The client is avoiding discussion of her illness and postoperative orders. In going over discharge instructions with the client, the nurse: A) Teaches the client's spouse B) Focuses on knowledge the client will need in a few weeks C) Provides only the information the client needs to go home D) Convinces the client that learning about her health is necessary
C. Provides only the information teh client needs to go home Because this client does need to have some postoperative knowledge, the teaching should focus on the information the client will need until she has had a chance to move through the grief process. Teaching the spouse does not focus on caring for the client, although his knowledge can be helpful. Teaching ahead about information that the client will need in a few weeks is not appropriate. Until the client is able to process her grief, convincing her that learning about health is not productive.
The nurse is demonstrating the proper technique for using a glucometer to a group of clients newly diagnosed with diabetes. The nurse smiles and praises one of the clients when she correctly performs a finger stick. This teaching approach is referred to as: A) Timing B) Entrusting C) Reinforcing D) Group instruction
C. Reinforcing Social reinforcement includes smiles, compliments, or words of encouragement. Timing is not a teaching approach. It refers to the planning phase of the teaching process. Entrusting allows the client to manage his or her own care, with the nurse available for assistance if needed. A client newly diagnosed with diabetes would not be able to manage self-care. Group instruction is an instructional method, not a teaching approach.
The nurse feels a client is at risk for skin breakdown because he has only had clear liquids for the last 10 days (and essentially no protein intake). The nurse would formulate which diagnostic statement that would best reflect this problem? A. Risk for malnutrition related to clear liquid diet B. Impaired skin integrity related to no protein intake C. Risk for impaired skin integrity related to malnutrition D. Impaired nutrition related to current illness
C. Risk for impaired skin integrity related to malnutrition Rationale: This is a risk diagnosis, and the diagnostic statement has two parts: the human response (impaired skin integrity) and the related/risk factor (malnutrition). Options 1 and 2 do not have related factors that are under the control of the nurse (i.e., type of diet ordered). The diagnosis in option 4 does not specify the type of impairment (greater than or less than body requirements) and is therefore incomplete. It also does not provide direction for development of goals and interventions.
Which of the following terms is defined as a mental self-image of strengths and weaknesses in all aspects of one's personality? A) Body image B) Family roles C) Self-concept D) Emotional change
C. Self-concept Self-concept is a mental self-image of strengths and weaknesses in all aspects of one's personality. Self-concept is important in relationships with other family members. When a client is ill, his or her self-concept changes and this may lead to tension and conflict. Body image is defined as a subjective concept of physical appearance. Many illnesses can cause changes in physical appearance, and clients and families react differently to these changes. Clients react differently to illness or the threat of illness. Individual behavioral and emotional reactions depend on the nature of the illness. Illness impacts family roles. When an illness occurs, parents and children try to adapt to major changes resulting from a family member's illness.
A nurse is completing discharge teaching to a client who has COPD. The nurse should identify that the client understands the orthopneic position when she states will do which of the following when she has difficulty breathing at night? A. Lie on her back with her head and shoulders on a pillow B. Lie flat on my stomach with her head to one side. C. Sit on the side of her bed and rest her arms over pillows on top of her bedside table. D. Lie on her side with her weight on her hips and shoulder with her arm flexed in front of her.
C. Sit on the side of her bed and rest her arms over pillows on top of her bedside table.
All of the following are considered internal variables that influence a client's health beliefs and practices except: A) Emotional factors B) Developmental stage C) Socioeconomic factors D) Perception of functioning
C. Socioeconomic factors Socioeconomic factors are considered external variables. A person seeks approval and support from neighbors, peers, and co-workers; this affects health beliefs and practices. Economic variables may affect a client's level of health. For example, a client with a fixed income who needs long-term medications may determine that food and shelter are more important than the medication; therefore, the client's health suffers. Perception of functioning is an internal variable. It is defined as the way an individual perceives his or her physical functioning and how it affects health beliefs and practices. Emotional factors are internal variables. These include a client's degree of stress, depression, or fear, which can influence health beliefs and practices. An individual's developmental stage is considered an internal variable. A client's thinking about health is dependent on his or her level of development.
A client comes into the clinic for a complete physical examination. The nurse obtains a health history and determines that the client is at risk for heart disease. Which of the following would lead the nurse to conclude this? A) The client is 25 years old. B) The client lives near a chemical plant. C) The client's father died of a heart attack at age 40. D) The client works as a carpet salesman.
C. The client's father died of a heart attack at age 40 Genetic predisposition to specific illnesses is considered a major physical risk factor. The client's father died of a heart attack at the age of 40, which increases the client's risk of heart disease and heart attack. Age may increase or decrease a client's susceptibility to certain illnesses. Age risk factors are often closely associated with other risk factors, such as family history and personal habits. The client is 25 years old; therefore, based on age alone, risk is low for heart disease at this time. The client lives near a chemical plant; this constant exposure to chemicals may lead to health problems. The physical environment in which a person works and lives can increase the likelihood that certain illnesses will occur, but without further information the nurse cannot assess the heart disease risk related to the client's possible chemical exposure.
A nurse is assigned to a client who has returned from the recovery room following surgery for a colorectal tumor. After an initial assessment, the nurse anticipates the need to monitor the client's abdominal dressing, intravenous infusion, and drainage tubes. The client is in pain and will not be able to eat or drink until intestinal function returns. The nurse will have to establish priorities of care in which of the following situations? A) The family comes to visit the client. B) The client expresses concern about pain control. C) The client's vital signs change showing a drop in blood pressure. D) The charge nurse approaches the assigned nurse and requests a report at the end of the shift.
C. The client's vital signs change showing a drop in blood pressure A drop in blood pressure indicates a possible emergency situation, including bleeding at the surgical site. Concern about pain control, including a thorough assessment focusing the client's pain, would be the second priority. The end-of-shift report and the family's visit are lesser priorities.
Which nurse is demonstrating the assessment phase of the nursing process? A.The nurse who observes that the client's pain was relieved with pain medication B. The nurse who turns the client to a more comfortable position C. The nurse who ask the client how much lunch he or she ate D. The nurse who works with the client to set desired outcome goals
C. The nurse who ask the client how much lunch he or she ate Rationale: Assessment involves collecting, organizing, validating, and documenting data about a client. Option 1 represents the evaluation phase. Option 2 represents the implemention phase. Option 4 represents the planning phase.
In the examples given below, which nurse is acting to avoid a data collection error? A) The nurse asks her colleague to chart her assessment data. B) The nurse considers conflicting cues in deciding on the correct nursing diagnosis. C) The nurse who assesses the edema in a client's lower leg is unsure of its severity and asks her co-worker to check it with her. D) After performing an assessment the nurse critically reviews his level of comfort and competence with interviewing and physical assessment skills.
C. The nurse who assesses the edema in a client's lower leg is unsure of its severity and asks her co-worker to check it with her. A nurse who is uncertain and asks a colleague to consult is avoiding a data collection error. The nurse reviewing his level of comfort and competence is being complete but can miss his own errors. Considering conflicting clues does not help avoid data collection errors. Asking a colleague to chart data is incorrect.
4. There is a contemporary move toward addressing nursing as a science or as evidenced-based practice. This suggests that: A) One theory will guide nursing practice. B) Scientists will make nursing decisions. C) Theories will be tested to describe or predict client outcomes. D) Nursing will base client care on the practice of other sciences.
C. Theories will be testing to describe or predict client outcomes Theories will be tested to describe or predict client outcomes as nursing is addressed as a science and an art. Scientists will not make nursing decisions, and nursing will base client care on the practice of nursing science, which will be guided by multiple theories.
Which of the following statements about prescriptive theories is accurate? A) They describe phenomena. B) They have the ability to explain nursing phenomena. C) They reflect practice and address specific phenomena. D) They provide a structural framework for broad abstract ideas.
C. They reflect paractice and address specific phenomena Prescriptive theories address nursing interventions for a phenomenon and predict the consequence of a specific nursing intervention. Descriptive theories describe the phenomena, speculate on the reason the phenomena occur, and predict nursing phenomena. Grand theories are broad and complex and provide a structural framework for broad, abstract ideas about nursing.
A female client who is receiving chemotherapy asks the nurse if she can have a fresh green salad because she is nauseated. Which response should the nurse provide?
Canned vegetables are recommended while taking chemotherapy.
Florence Nightingale did many significant things in her lifetime, some of those include:
Challenged prejudices against women. Elevated the status of nurses Established the first "proper" training of nurses. *Based nursing practice on evidence.* Helped distinguish nursing from medicine.
Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status?
Chocolate pudding.
A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take?
Commend the client for selecting a high biologic value protein.
The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? A. The belief is held that the "evil eye" enters the child if anything cold is ingested. B. After surgery the child probably has refused all foods except broth. C. Eating broth strengthens the child's innate energy called "chi." D. Hot remedies restore balance after surgery, which is considered a "cold" condition.
Common parental practices and health beliefs among Hispanic, Chinese, Filipino, and Arab cultures classify diseases, areas of the body, and illnesses as "hot" or "cold" and must be balanced to maintain health and prevent illness. The perception that surgery is a "cold" condition implies that only "hot" remedies, such as soup, should be used to restore the healthy balance within the body, so (D) is the correct interpretation. (A, B, and C) are not correct interpretations of the noted behavior. "Chi" is a Chinese belief that an innate energy enters and leaves the body via certain locations and pathways and maintains health. The "evil eye," or "mal ojo," is believed by many cultures to be related to the balance of health and illness but is unrelated to dietary practice. Correct Answer: D
45.A 35-year-old female client with cancer refuses to allow the nurse to insert an IV for a scheduled chemotherapy treatment, and states that she is ready to go home to die. What intervention should the nurse initiate? A. Review the client's medical record for an advance directive. B. Determine if a do-not-resuscitate prescription has been obtained. C. Document that the client is being discharged against medical advice. D. Evaluate the client's mental status for competence to refuse treatment.
Competent clients have the right to refuse treatment, so the nurse should first ensure that the client is competent (D). (A and C) are not necessary for a competent client to refuse treatment. The nurse cannot document (C) until the healthcare provider is notified of the client's wishes and a discharge prescription is obtained. Correct Answer: D
The nurse is caring for a client who is the daughter of a local politician. When the nurse approaches a man who is reading names on the hall doors, he identifies himself as a reporter for the local newspaper and requests information about the client's status. Which standard of nursing practice should the nurse use to respond?
Confidentiality
The nurse notices that the mother of a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take?
Continue asking the mother questions about the child.
When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? A. Complimentary healing practices interfere with the efficacy of the medical model of treatment. B. Conventional medications are likely to interact with folk remedies and cause adverse effects. C. Many complimentary healing practices can be used in conjunction with conventional practices. D. Conventional medical practices will ultimately replace the use of complimentary healing practices.
Conventional approaches to health care can be depersonalizing and often fail to take into consideration all aspects of an individual, including body, mind, and spirit. Often complimentary healing practices can be used in conjunction with conventional medical practices (C), rather than interfering (A) with conventional practices, causing adverse effects (B), or replacing conventional medical care (D). Correct Answer: C
Which profession is at greatest risk for acquiring Hep A.
Cook in a restaurant
42.The nurse notes that a client consistently coughs while eating and drinking. Which nursing diagnosis is most important for the nurse include in this client's plan of care? A. Ineffective breathing pattern. B. Impaired gas exchange. C. Risk for aspiration. D. Ineffective airway clearance.
Coughing during or after meals is a manifestation of dysphagia, or difficulty swallowing, which places the client at risk for aspiration (C). Dysphagia can lead to aspiration pneumonia, but the client is not currently exhibiting any symptoms of breathing difficulty (A) or impaired gas exchange (B). Although (D) may be related to an ineffective cough, the client's coughing is an effective response when solids or liquids are taken orally. Correct Answer: C
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? A. Record the coughing incident. No further action is required at this time. B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.
Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking any other action (C). (A and B) are not indicated. The auscultating method (D) has been found to be unreliable for small-bore feeding tubes. Correct Answer: C
client expresses concern about being exposed to radiation therapy because it can cause cancer. What should the nurse emphasize when informing the client about exposure to radiation? 1 The dosage is kept at a minimum. 2 Only a small part of the body is irradiated. 3 The client's physical condition is not a risk factor. 4 Nutritional environment of the affected cells is a risk factor.
Current radiation therapy accurately targets malignant lesions with pinpoint precision, minimizing the detrimental effects of radiation to healthy tissue. The dose is not as significant as the extent of tissue being irradiated. When radiation therapy is prescribed, the health care provider takes into consideration the ability of the client to tolerate the therapy, determining that the benefit outweighs the risk. Nutritional environment of the affected cells does not influence radiation's effect.
The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive? A) 31 gtt/min. B) 62 gtt/min. C) 93 gtt/min. D) 124 gtt/min
D) 124 gtt/min
A couple has brought in their adolescent daughter for a school physical. The parents tell the nurse that they are worried about all the safety risks for this age group. As the nurse plans to teach the parents about these risks, the nurse remembers that adolescents are at a greater risk for injury from: A) Home accidents B) Poisoning and child abduction C) Physiological changes of aging D) Automobile accidents, suicide, and substance abuse
D) Automobile accidents, suicide, and substance abuse Adolescents are more likely to be involved in automobile accidents, commit suicide, and engage in substance abuse than are those in other age groups. Children are more susceptible to poisoning and child abduction, and older adults are more susceptible to home accidents and the physiological changes of aging.
6. A gown should be worn when: A) The client's hygiene is poor. B) The client has acquired immunodeficiency syndrome (AIDS) or hepatitis. C) The nurse is assisting with medication administration. D) Blood or body fluids may get on the nurse's clothing from a task the nurse plans to perform.
D) Blood or body fluids may get on the nurse's clothing from a task the nurse plans to perform. Gowns should be worn when there is a possibility that blood or body fluids could get on the nurse's clothes or when the client is on contact isolation status. The other options are not appropriate uses of gowns.
A child for which the nurse is caring in the hospital starts to have a grand mal seizure while playing in the playroom. What is the most important intervention the nurse can do during this situation? A) Begin cardiopulmonary resuscitation. B) Restrain the child to prevent injury. C) Place a tongue blade over the tongue to prevent aspiration. D) Clear the area around the child to protect the child from injury.
D) Clear the area around the child to protect the child from injury. An area around the child should be cleared to prevent injury. Restraining the child or placing a tongue blade in the child's mouth may actually be a cause of injury. Cardiopulmonary resuscitation is required only if heart function stops after the seizure.
A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement? A) Obtain the pre-transfusion hemoglobin level. B) Prime the tubing and prepare a blood pump set-up. C) Monitor vital signs q15 minutes for the first hour. D) Ensure the accuracy of the blood type match.
D) Ensure the accuracy of the blood type match All interventions should be implemented prior to administering blood, but (D) has the highest priority. Any time blood is administered, the nurse should ensure the accuracy of the blood type match in order to prevent a possible hemolytic reaction
The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? A) The belief is held that the "evil eye" enters the child if anything cold is ingested. B) After surgery the child probably has refused all foods except broth. C) Eating broth strengthens the child's innate energy called "chi." D) Hot remedies restore balance after surgery, which is considered a "cold" condition.
D) Hot remedies restore balance after surgery, which is considered a "cold" condition Common parental practices and health beliefs among Hispanic, Chinese, Filipino, and Arab cultures classify diseases, areas of the body, and illnesses as "hot" or "cold" and must be balanced to maintain health and prevent illness. The perception that surgery is a "cold" condition implies that only "hot" remedies, such as soup, should be used to restore the healthy balance within the body, so (D) is the correct interpretation. (A, B, and C) are not correct interpretations of the noted behavior. "Chi" is a Chinese belief that an innate energy enters and leaves the body via certain locations and pathways and maintains health. The "evil eye," or "mal ojo," is believed by many cultures to be related to the balance of health and illness but is unrelated to dietary practice.
The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? A) Place the chair at a right angle to the bed on the client's left side before moving. B) Assist the client to a standing position, then place the right hand on the armrest. C) Have the client place the left foot next to the chair and pivot to the left before sitting. D) Move the chair parallel to the right side of the bed, and stand the client on the right foot
D) Move the chair parallel to the right side of the bed, and stand the client on the right foot (D) uses the client's stronger side, the right side, for weight-bearing during the transfer, and is the safest approach to take. (A, B, and C) are unsafe methods of transfer and include the use of poor body mechanics by the caregiver.
An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A) Reaffirm the client's desire for no resuscitative efforts. B) Transfer the client to a hospice inpatient facility. C) Prepare the family for the client's impending death. D) Notify the healthcare provider of the family's request.
D) Notify the healthcare provider of the family's request The nurse should first communicate with the healthcare provider (D). Hospice care is provided for clients with a limited life expectancy, which must be identified by the healthcare provider. (A) is not necessary at this time. Once the healthcare provider supports the transfer to hospice care, the nurse can collaborate with the hospice staff and healthcare provider to determine when (B and C) should be implemented
During the night shift a client is found wandering the hospital halls looking for a bathroom. The nurse's initial intervention would be to: A) Insert a urinary catheter. B) Ask the physician to order a restraint. C) Assign a staff member to stay with the client. D) Provide scheduled toileting during the night shift.
D) Provide scheduled toileting during the night shift. Providing scheduled toileting during the night makes it less likely that a client will wander while being confused and ensures staff presence to decrease confusion at the times when the client is away from bed. Inserting a urinary catheter is not necessary. Assigning a staff member to stay with the client might not be necessary if the scheduled toileting is successful. Restraints are unnecessary in this case.
An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? A) Generalized dry skin. B) Localized dry skin on lower extremities. C) Red flush over entire skin surface. D) Rashes in the axillary, groin, and skin fold regions
D) Rashes in the axillary, groin, and skin fold regions Immobility, constant contact with bed clothing, and excessive heat and moisture in areas where air flow is limited contributes to bacterial and fungal growth, which increases the risk for rashes (D), skin breakdown, and the development of pressure ulcers. (A, B, and C) do not address the concepts of inflammation and tissue integrity
The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? A) Encourage the client to cough to help loosen secretions. B) Advise the client to increase the intake of oral fluids. C) Rotate the suction catheter to obtain any remaining secretions. D) Re-oxygenate the client before attempting to suction again.
D) Re-oxygenate the client before attempting to suction again Suctioning should not be continued for longer than ten to fifteen seconds, since the client's oxygenation is compromised during this time (D). (A, B, and C) may be performed after the client is re-oxygenated and additional suctioning is performed.
5. Lisa, a nurse assistant, is working with the nurse during the nurse's shift. One of the nurse's clients has upper limb restraints. In delegating care of this client to Lisa, the nurse would tell her to: A) Secure the restraints to the side rails. B) Check to see if the client can have a medication for sleep. C) Call the physician if the client becomes more agitated with the restraint. D) Report any signs of redness, excoriation, or constriction of circulation under the restraint.
D) Report any signs of redness, excoriation, or constriction of circulation under the restraint. The restraint sites much be checked regularly for signs of redness, excoriation, or constriction, and this task may be delegated. Calling the physician and performing medication assessments are nursing responsibilities. Restraints should never be secured to the side rails.
After the nurse assists a client with a history of seizures to a recliner chair, the client begins to have a seizure. The nurse should immediately: A) Turn the client onto his or her stomach. B) Recline the client's chair all the way back. C) Return the client to the bed and place the client on his or her side. D) Slide the client to the floor and cradle the client's head in the nurse's lap.
D) Slide the client to the floor and cradle the client's head in the nurse's lap. The nurse's lap is the safest position for the client's head, and the client is less likely to sustain an injury if the client is already on the floor. Attempting to move the client laterally by oneself could result in injury to the client and/or nurse. Placement in a reclining position could cause excess secretions to accumulate in the oral pharynx and obstruct the airway. Turning the client onto his or her stomach would decrease access to the airway.
An Arab-American woman, who is a devout traditional Muslim, lives with her married son's family, which includes several adult children and their children. What is the best plan to obtain consent for surgery for this client? A) Obtain an interpreter to explain the procedure to the client. B) Encourage the client to make her own decision regarding surgery. C) Ask the family members to provide an interpretation of the surgeon's explanation to the client. D) Tell the surgeon that the son will decide after explanation of the proposed surgery is provided.
D) Tell the surgeon that the son will decide after explanation of the proposed surgery is provided Traditional Muslim women live in a patriarchal family where decisions are made by men. Most likely, the son will make the decision for his mother, so (D) provides the surgeon with culturally sensitive information. (A) may be necessary if a language barrier exists, but the son is the patriarch in the client's family at this time. It is culturally insensitive to encourage the woman to go against her religious and cultural worldview, as in (B). Family members are more likely to misinterpret medical information, but the son should be the primary decision-maker for his mother (C).
4. A nurse is assigned to care for a client with a deep wound infection. Which of the following actions would result in the contamination of sterile gloves? A) The nurse grasps a sterile cotton-tipped swab to clean wound edges. B) The nurse takes a gauze pad in hand and places it in the wound. C) The nurse picks up a gauze pad soaked in sterile saline to cleanse the wound. D) The nurse pulls up the sheet over the client's perineum for better draping.
D) The nurse pulls up the sheet over the client's perineum for better draping. If the nurse touches a sheet (nonsterile) with sterile gloves, the gloves are contaminated. The other actions do not contaminate sterile gloves.
Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent? A) Height in inches or centimeters. B) Weight in kilograms or pounds. C) Triceps skin fold thickness. D) Upper arm circumference.
D) Upper arm circumference Upper arm circumference (D) is an indirect measure of muscle mass. (A and B) do not distinguish between fat (adipose) and muscularity. (C) is a measure of body fat.
A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? A) demonstrates loss of remote memory. B) exhibits expressive dysphasia. C) has a diminished attention span. D) is disoriented to place and time.
D) is disoriented to place and time The client is exhibiting disorientation (D). (A) refers to memory of the distant past. The client is able to express himself without difficulty (B), and does not demonstrate a diminished attention span (C).
A nurse is performing skin assessments on a group of clients. Which of the following lesions should the nurse identify as vesicles? Select all that apply. a. Acne b. Warts c. Psoriasis d. Herpes simplex e. Varicella
D, E
A security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses. Which of the following statements by a nurse indicates understanding of proper procedure? A. "I will get the caller off the phone as soon as possible so I can alert the staff" B. "I will begin evacuating clients using the elevator" C. "I will not ask any questions and just let the caller talk" D. "I will listen for background noises"
D. "I will listen for background noises"
Mishel's theory of uncertainty in illness focuses on the experience of clients with cancer who live with continual uncertainty. The theory provides a basis for nurses to assist clients in appraising and adapting to the uncertainty and illness response and can be described as: A) A grand theory B) A descriptive theory C) A prescriptive theory D) A middle-range theory
D. A middle-range theory Middle-range theories are limited in scope, less abstract than grand theories, address specific phenomena or concepts, and reflect practice. Grand theories are described as broad and complex. Prescriptive theories address nursing interventions and predict the consequence of a specific nursing intervention. Descriptive theories describe phenomena, speculate as to why the phenomena occur, and describe the consequences of phenomena
An older man is being given a new antihypertensive medication. In teaching the client about the medication, the nurse should: A) Speak loudly. B) Present the information once. C) Expect the client to understand the information quickly. D) Allow the client time to express himself and ask questions.
D. Allow the client time to express himself and ask questions The nurse should allow the client time to express himself and ask questions. Speaking loudly is typically not effective, and information may have to be presented several times. The client will learn the information at his own speed.
A charge nurse is assigning rooms for the clients to be to the unit. To prevent falls, which of the following clients should the nurse assign to the room closest to the nurses' station? A. A middle adult who is postoperative following a laparoscopic cholecystectomy B. A middle adult who requires telemetry for a possible myocardial infarction C. A young adult who is postoperative following an open reduction internal fixtion of the ankle D. An older adult who is postoperative following a below-the-knee amputation
D. An older adult who is postoperative following a below-the-knee amputation
On entering a client's room during change-of-shift rounds, the nurse notices that the client and spouse have their backs turned to each other, and both have their arms folded across their chests. The best action for the nurse to take at this time is to: A) Introduce himself or herself and begin discharge teaching. B) Proceed with the tasks the nurse was intending to perform. C) Say nothing and leave quickly, closing the door behind. D) Ask the client and spouse if they need some time alone right now.
D. Ask the client and spouse if they need smoe time alone right now. The situation suggests that the nurse entered during a stressful time. Offering privacy would be appropriate. Because the situation indicates tension between the couple, this is not the time to initiate teaching.
A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time? A. Obtain a walker for the client to use to transfer back to bed. B. Call for additional staff to assist with the transfer. C. Use a transfer belt and assist the client into bed. D. Determine the client's ability to help with the transfer.
D. Assess the client's ability to help with the transfer.
Which of the following is an example of an expected outcome statement in measurable terms? A) Client will be pain free. B) Client will have less pain. C) Client will take pain medication every 4 hours. D) Client will report pain intensity of less than 4 on a scale of 0 to 10.
D. Client will report pain intensity of less than 4 on a scale of 0 to 10 Reporting the level of pain on a numbered scale is a measurable, objective goal. The other options do not specify measurable outcomes.
The surgical unit has initiated the use of a pain rating scale to assess the severity of clients' pain during their postoperative recovery. The nurse assigned to a client can look at the pain flow sheet to see the client's pain scores over the last 24 hours. Use of the pain scale is an example of adherence to which intellectual standard?
D. Consistency Using the same pain scale for all clients and ratings promotes consistency—each nurse has the same measurement scale to compare assessments. Relevance refers to how applicable the assessment is. An assessment has depth when it deals with less obvious issues. Specificity refers to the ability of the assessment to provide information about the particular problem of interest.
The nurse requests a stimulant laxative for a client who is receiving an opioid around the clock. What is the nurse demonstrating? A) Concern for safety B) Promotion of client health C) Colleague health education D) Control of adverse reactions
D. Control of adverse reactions The nurse is demonstrating knowledge of opioid side effects and being proactive by asking for an intervention that will most likely prevent the side effect of constipation associated with opioids. The intervention does not promote health; it is aimed at preventing a side effect of an opioid. Safety is not an issue. Requesting a laxative does not provide education.
A theory is a set of concepts, definitions, relationships, and assumptions or propositions to explain a phenomenon. The purposes of the components of a theory are to: A) Describe concepts or connect two concepts that are factual B) Formulate a perceptual experience to describe or label a phenomenon C) Express the global view about the individual, situations, or factors of interest to a specific discipline D) Describe, explain, predict, and/or prescribe interrelationships among the concepts that define the phenomenon
D. Describe, explain, predict, and/or prescribe interrelationships among the concepts that define the phenomenon Describing, explaining, predicting, and/or prescribing interrelationships among concepts are stated purposes of research.
During the change-of-shift report the night nurse states that a client mentioned having a bad experience with surgery in the past. The nurse was called away and was unable to continue the conversation with the client. The nurse tells the day shift nurse about the comment and notes that the client appears anxious. When the day shift nurse visits the client to clarify the client's bad experience with surgery, the nurse is exhibiting which aspect of critical thinking? A. Integrity B. Discipline C. Confidence D. Perseverance
D. Discipline Discipline includes completing the task at hand, including assessments (which were not completed on the previous shift). Integrity includes recognizing when one's opinions conflict with those of others and finding a mutually satisfying solution. Confidence is demonstrated in one's presentation and belief in one's knowledge and abilities. Perseverance helps the critical thinker to find effective solutions to client care problems, especially when they have been previously unresolved.
Twenty minutes after administering pain medication to the client, the nurse returns to ask if the client's level of pain has decreased. The nurse documents the client's response as part of which phase of the nursing process? A. Diagnosis B. Planning C. Implementation D. Evaluation
D. Evaluation Rationale: Evaluating is the process of comparing client responses to the outcome goals to determine whether, or to what degree, goals have been met. Diagnosing identifies health problems, risks, and strengths. Planning is the formulation of client goals and nursing strategies (interventions) required to prevent, reduce, or eliminate the client's health problems. Implementing is carrying out or delegating the nursing interventions.
All of the following are examples of active strategies of health promotion except: A) Exercise training B) Weight reduction C) Smoking cessation D) Fluoridation of drinking water
D. Fluoridation of drinking water Passive strategies of health promotion benefit individuals without any action by the individuals themselves. The fluoridation of municipal drinking water and the fortification of homogenized milk with vitamin D are examples of passive health promotion strategies. Weight reduction is considered an active strategy of health promotion. With active strategies of health promotion, individuals are motivated to adopt specific health programs. Smoking cessation requires clients to be actively involved in measures to improve their present and future levels of wellness while decreasing the risk of disease. Exercise training meets the criteria for active strategies of health promotion because it actively involves the client in his or her own health.
A nurse assessing a client who comes to the pulmonary clinic asks, "Tell me what medications you are taking for your breathing problem. I see from your last visit that Dr. Russell recommended routine exercise. Can you also tell me how successful you have been in following his plan?" The nurse's assessment covers which of Gordon's functional health patterns? A) Value-belief pattern B) Cognitive-perceptual pattern C) Coping/stress tolerance pattern D) Health perception/health management pattern
D. Health perception/health management patern The health perception/health management pattern involves the client's self-report of health and well-being, how the client manages his or her health, and knowledge of preventative health practices. The cognitive-perceptual pattern involves sensory-perceptual patterns, language adequacy, memory, and decision-making abilities. The coping/stress tolerance pattern involves the client's ability to manage stress, sources of support, and the effectiveness of the patterns in terms of stress tolerance. The value-belief pattern involves the values, beliefs, and goals that guide the client's choices or decisions.
Assessment data must be descriptive, concise, and complete. In performing an assessment the nurse should not: A) Include subjective data from the client. B) Perform a thorough physical examination. C) Use interpersonal and cognitive skills. D) Include inferences or interpretative statements not supported with data.
D. Include inferences or interpretative statements not supported with data The nurse should not generalize or form judgments not supported by the collected data. Inferences and interpretive statements must be supported by data. Assessments do include conducting a thorough physical examination, using interpersonal and cognitive skills, and obtaining subjective data from the client.
A nurse has set a time limit for expected outcomes. What is the purpose of establishing such a time frame? A) Indicate which outcome has priority. B) Indicate the time it takes to complete an intervention. C) Indicate how long the nurse is scheduled to care for the client. D) Indicate when the client is expected to respond in the desired manner.
D. Indicate when the client is expected to respond in the dsired manner The time limit sets measurable points to evaluate the client's response and movement toward meeting the outcome goals. The other options are incorrect.
The health belief model addresses the relationship between a person's belief and behaviors, therefore: A) A person who smokes does not follow the model. B) This model provides a basis for caring for clients of all ages. C) A person who does not take necessary medications does not follow the model. D) It provides a way of understanding and predicting how clients will behave in relation to their health and how they will comply with health care regimens.
D. It provides a way of understanding and predicting how clients will behave in relation to their health and how they will comply with health care regimens. The health belief model provides a way of understanding and predicting how clients will behave in relation to their health and how they will comply with health care regimens.
A client who is alert and awake is being transferred to another hospital with a copy of his medical records. Before the transfer the nurse must: A) Ask the hospital lawyer if this requires approval from the risk management department. B) Discuss the need to copy the medical records with the client's family. C) Be certain that the physician writes an order for the record to be copied. D) Obtain written permission to copy the medical records for the receiving hospital.
D. Obtain written permissin to copy the medical records for the receiving hospital Obtaining permission to copy the records demonstrates the nurse's understanding of the provisions of the Health Insurance Portability and Accountability Act (HIPAA). Discussing medical records with the client's family is inappropriate because the client's family does not make the decision for a client who is capable of making his own decision. Policies and procedures would already be in place for the nurse with regard to copying medication records. It is not necessary to call the hospital lawyer. Copying a client's medical record does not require a physician's order.
A client needs to learn to use a walker. Acquisition of this skill will require learning in which domain? A) Affective domain B) Cognitive domain C) Attentional domain D) Psychomotor domain
D. Psychomotor domain The psychomotor domain concerns motor skills. The cognitive domain involves understanding, and the affective domain involves attitudes. The attentional domain is not a recognized domain. Attentional set is the mental state that allows the learner to focus on and comprehend a learning activity.
A client with diabetes mellitus who takes daily insulin injections is scheduled for surgery the next day. The client is to take nothing by mouth (NPO status) after midnight. The nurse questions whether insulin should be given the morning of surgery. This is an example of: A) Problem solving B) Previous experience C) Clinical practice guideline D) Scientifically based clinical judgment
D. Scientifially based clinical judgment The nurse is demonstrating awareness of the effect of insulin, which is to lower blood glucose level. Because the client will be NPO status for a long period of time, no calories will be consumed. Giving the usual injection of insulin could cause the client to experience hypoglycemia.
As an art, nursing relies on knowledge gained from practice and reflection on past experiences. As a science, nursing relies on: A) Experimental research B) Nonexperimental research C) Physician-generated research D) Scientifically tested knowledge
D. Scientifically tested knowledge As a science, nursing draws on scientifically tested knowledge applied in the practice setting.
A nurse working in a special care unit for children with severe immunologic problems cares for a 3-year-old boy from Greece. The nurse is having difficulty communicating with the father. What is the appropriate action? A) Care for the boy the same as for any other client. B) Ask the manager to talk with the father and keep him out of the unit. C) Have another nurse care for the boy, because maybe that nurse will communicate better with the father. D) Search for help in interpreting and understanding the culture differences by contacting someone from the local Greek community.
D. Search for help in interpreting and understanding the culture differences by contacting someone from the local Greek community Acquiring cultural and language assistance will help the nurse understand the needs of both the father and the son. The other three options are not culturally sensitive or helpful to the client and his father.
The nurse in a diabetic clinic conducts monthly seminars for diabetic clients. During these seminars, the importance of taking insulin as directed to prevent diabetic complications is emphasized. This is considered which level of preventive care? A) Illness prevention B) Tertiary prevention C) Primary prevention D) Secondary prevention
D. Secondary prevention Secondary prevention is prevention geared toward individuals who are already experiencing health problems or illness and who are at risk of experiencing complications or a worsening of their condition
A nurse is going to teach a client how to perform a breast self-examination. Which of the following statements is the behavioral objective that best measures the client's ability to perform the examination? A) The nurse will discuss learning objectives. B) The client will verbalize the steps involved in breast self-examination within 1 week. C) The nurse will explain the importance of performing breast self-examination once a month. D) The client will demonstrate breast self-examination on herself by the end of the teaching session.
D. The client will demonstrate breast self-examination on herself by the end of the teaching session. Option D has a measurable outcome at a specific time. Options A and B do not show that the client has learned to perform the examination. Option C does not show learning.
Which of the following is an example of an appropriately stated learning objective? A) The client will ambulate 100 feet. B) The nurse will explain the importance of a diabetic diet. C) The nurse will demonstrate a sterile dressing change by the end of the first hospital day. D) The client will state three factors that affect cholesterol by the end of the teaching session.
D. The client will state three factors that affect cholesterol by the end of the teaching session. This learning objective includes the required singular behavior, measurable objective, and time frame for completion. Option 1 lacks a time frame for completion and is a behavioral objective. Options 2 and 3 are teaching objectives rather than learning objectives.
A client-centered goal is a specific and measurable behavior or response that reflects: A) The physician's goal for the specific client B) The client's desire for specified health care interventions C) The client's response compared to that of another client with a similar problem D) The client's highest possible level of wellness and independence in function
D. The client' highest possible level of wellness and independence in function A client-centered goal is a specific and measurable behavior or response that reflects a client's highest possible level of wellness and independence in function. The other options do not meet the definition of a client-centered goal.
The nursing diagnosis 'Readiness' for enhanced communication is an example of which of the following? A) Risk nursing diagnosis B) Actual nursing diagnosis C) Potential nursing diagnosis D) Wellness nursing diagnosis
D. Wellness nursing diagnosis The term readiness indicates a wellness nursing diagnosis. An actual nursing diagnosis describes a human response to health conditions or life processes in an individual, family, or community. A potential nursing diagnosis is a risk for diagnosis.
During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? A. Provide additional coffee on the client's breakfast tray. B. Exchange the client's grape juice for cranberry juice. C. Bring the client additional fruit at mid-morning. D. Encourage additional oral intake of juices and water.
Dark amber urine is characteristic of fluid volume deficit, and the client should be encouraged to increase fluid intake (D). Caffeine, however, is a diuretic (A), and may worsen the fluid volume deficit. Any type of juice will be beneficial (B), since the client is not dysuric, a sign of an urinary tract infection. The client needs to restore fluid volume more than solid foods (C). Correct Answer: D
76.In assessing a client's femoral pulse, the nurse must use deep palpation to feel the pulsation while the client is in a supine position. What action should the nurse implement? A. Elevate the head of the bed and attempt to palpate the site again. B. Document the presence and volume of the pulse palpated. C. Use a thigh cuff to measure the blood pressure in the leg. D. Record the presence of pitting edema in the inguinal area.
Deep palpation may be required to palpate the femoral pulse; and, when palpated, the nurse should document the presence and volume of the pulse (B). The site is best palpated with the client supine; elevation of the head of the bed requires even deeper palpation (A). The use of deep palpation to feel the femoral pulse does not indicate a problem requiring further assessment, such as (C), and does not reflect the presence of edema (D). Correct Answer: B
70.The home health nurse visits an elderly client who lives at home with her husband. The client is experiencing frequent episodes of diarrhea and bowel incontinence. Which problem, for which the client is at risk, has the greatest priority when planning the client's care? A. Disturbed sleep pattern. B. Caregiver role strain. C. Impaired skin integrity. D. Fluid volume imbalance.
Diarrhea can lead to fluid volume loss, which is potentially life-threatening, so the highest priority is to prevent a fluid volume imbalance (D). Diarrhea and bowel incontinence can also lead to (A, B, and C), but these are of less potential harm than a fluid volume deficit. Correct Answer: D
An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct? A. Inquire about the source and type of pain. B. Examine the nose for congestion and discharge. C. Take vital signs for temperature elevation. D. Explore the abdominal area for distension.
Different cultural groups often have their own terms for health conditions. African-American clients may refer to pain as "the miseries. " Based on understanding this term, the nurse should conduct a focused assessment on the source and type of pain (A). (B, C, and D) are important, but do not focus on "miseries" (pain). Correct Answer: A
62.A client provides the nurse with information about the reason for seeking care. The nurse realizes that some information about past hospitalizations is missing. How should the nurse obtain this information? A. Solicit information on hospitalization from the insurance company. B. Look up previous medical records from archived hospital documents. C. Ask the client to discuss previous hospitalizations in the last 5 years. D. Elicit specific facts about past hospitalizations with direct questions.
Direct questions should be used after the client's opening narrative to fill in any details that have been left out or during the review of systems to elicit specific facts (D) about past health problems. (A and B) are time consuming, and may require the client's permission to access information about other hospitalizations. (C) may not produce the specific data needed. Correct Answer: D
The nurse is caring for a client who is unable to void. The plan of care establishes an objective for the client to ingest 1000 ml of fluid between 7 am and 3pm. Which client response should the nurse document that indicates a successful outcome?
Drinks 240mL of fluid 5 times during the shift
The duration of regular insulin is 4 to 6 hours; 3 to 5 hours is the duration for rapid-acting insulin such as Novolog. The duration of NPH insulin is 12 to 16 hours. The duration of Lantus insulin is 24 hours Humalog is a rapid-acting insulin. NPH is an intermediate-acting insulin. A short-acting insulin is Humulin-R. An example of a long-acting insulin is Glargine (Lantus)
Duration of Insulin is:
80.While preparing to insert a rectal suppository in a male adult client, the nurse observes that the client is holding his breath while bearing down. What action should the nurse implement? A. Advise the client to continue to bear down without holding his breath. B. Gently insert the lubricated suppository four inches into the rectum. C. Perform a digital exam to determine if a fecal impaction is present. D. Instruct the client to take slow deep breaths and stop bearing down.
During administration of a rectal suppository, the client is asked to take slow deep breaths through the mouth to relax the anal sphincter (D). Bearing down (A) will push the suppository out of the rectum, so the suppository should not be inserted while the client is bearing down (B). Further data is needed before performing an invasive digital exam to check for fecal impaction (C). Correct Answer: D
The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler?
During the inhalation
56.A female nurse who sometimes tries to save time by putting medications in her uniform pocket to deliver to clients, confides that after arriving home she found a hydrocodone (Vicoden) tablet in her pocket. Which possible outcome of this situation should be the nurse's greatest concern? A. Accused of diversion. B. Reported for stealing. C. Reported for a HIPAA violation. D. Accused of unprofessional conduct.
Even if this is only one incident, the nurse may be suspected of taking medications on a regular basis and the incident could be interpreted as diversion (A), or diverting narcotics for her own use, which should be reported to the peer review committee and to the State Board of Nursing. (B, C, and D) are also of concern, but (A) is the most serious possible outcome. Correct Answer: A
54.The nurse working in the emergency department is assessing four clients' ability to tolerate pain. Which client is likely to tolerate a higher level of pain? A. A 10-year-old who was burned by a camp fire earlier today. B. A 70-year-old who has a postoperative infection from a surgery one week ago. C. A 23-year-old woman who sprained her knee while bicycling. D. A 55-year-old woman who has had moderate low back pain for three months.
Experiences with the same type of pain that has successfully been relieved makes it easier for a client to interpret the pain sensation, and as a result, the client is better prepared to take steps to relieve the pain (D). (A, B, and C) are having new experiences with pain. Correct Answer: D
The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take? A. Talk directly to the child instead of the mother. B. Continue asking the mother questions about the child. C. Ask another nurse to interview the mother now. D. Tell the mother politely to look at you when answering.
Eye contact is a culturally-influenced form of non-verbal communication. In some non-Western cultures, such as the Vietnamese culture, a client or family member may avoid eye contact as a form of respect, so the nurse should continue to ask the mother questions about the child (B). (A, C, and D) are not indicated. Correct Answer: B
What is healthy people 2020?
Federal government indicative. Sort of like "Guidelines" for the US health standards.
Place each step of the nursing process in the order that it should be used. Correct 1. Obtain client's nursing history. Correct 2. State client's nursing needs. Correct 3. Identify goals for care. Correct 4. Develop a plan of care. Correct 5. Implement nursing interventions.
First the nurse should gather data. Based on the data, the client's needs are assessed. After the needs have been determined, the goals for care are established. The next step is planning care based on the knowledge gained from the previous steps. Implementation follows the development of the plan of care.
A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take? A. Commend the client for selecting a high biologic value protein. B. Remind the client that protein in the diet should be avoided. C. Suggest that the client also select orange juice, to promote absorption. D. Encourage the client to attend classes on dietary management of CRF.
Foods such as eggs and milk (A) are high biologic proteins which are allowed because they are complete proteins and supply the essential amino acids that are necessary for growth and cell repair. Although a low-protein diet is followed (B), some protein is essential. Orange juice is rich in potassium, and should not be encouraged (C). The client has made a good diet choice, so (D) is not necessary. Correct Answer: A
An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings?
Fowler's.
An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The nurse knows that the best position for this client during administration of the feedings is
Fowler's.
The nursing process is the _____________ for all nursing activities.
Framework
The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions?
Frontal lobe
Which action should the nurse implement when administering a prescription drug that should be given on an empty stomach?
Give one hour before or two hours after a meal; average transit time from stomach to duodenum is 2 hours
Which action is most important for the nurse to implement when donning sterile gloves? A. Maintain thumb at a ninety degree angle. B. Hold hands with fingers down while gloving. C. Keep gloved hands above the elbows. D. Put the glove on the dominant hand first.
Gloved hands held below waist level are considered unsterile (C). (A and B) are not essential to maintaining asepsis. While it may be helpful to put the glove on the dominant hand first, it is not necessary to ensure asepsis (D). Correct Answer: C
10.A middle-aged woman who enjoys being a teacher and mentor feels that she should pass down her legacy of knowledge and skills to the younger generation. According to Erikson, she is involved in what developmental stage? A. Generativity. B. Ego integrity. C. Identification. D. Valuing wisdom.
Healthy middle-aged adults focus on establishing the next generation by nurturing and guiding, which is describe by Erikson as the developmental stage of generativity (A), and is characteristic of middle adulthood. (B, C and D) are not stages of this age group according to Erickson's psychosocial developmental theory. Correct Answer: A
position most appropriate for the nurse to place a patient experiencing an asthma exacerbation
High Fowlers
To advance NG tube while inserting what position should the patient be in
High fowlers
33.A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to impending death." What intervention is best for the nurse to implement when caring for this client? A. Help the client to accept the final stage of life. B. Assist and support the client in establishing short-term goals. C. Encourage the client to make future plans, even if they are unrealistic. D. Instruct the client's family to focus on positive aspects of the client's life.
Hopefulness is necessary to sustain a meaningful existence, even close to death. The nurse should help the client set short-term goals, and recognize the achievement of immediate goals (B), such as seeing a family member, or listening to music. (A) is too vague to be a helpful intervention. (C) does not help the client deal with this nursing diagnosis. (D) might be implemented, but does not have the priority of (B). Correct Answer: B
38.The nurse encounters resistance when inserting the tubing into a client's rectum for a tap water enema. What action should the nurse implement? A. Withdraw the tube and apply additional lubricant to the tube. B. Encourage the client to bear down and continue to insert the tube. C. Remove the tube and check the client for a fecal impaction. D. Ask the client to relax and run a small amount of fluid into the rectum.
If resistance is encountered during the initial insertion of an enema tube, the client should be instructed to relax while a small amount of solution runs through the tube into the rectum (D) to promote dilation. (A) is unlikely to resolve the problem. (B) may cause injury. (C) should not be implemented until other, less invasive actions, such as (D) have been taken. Correct Answer: D
24.The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should the nurse take first? A. Check for a blood return. B. Reposition the client's arm. C. Remove the IV site dressing. D. Flush the lock with saline.
If the client's elbow is bent, the IV may be unable to infuse, resulting in an obstruction alarm, so the nurse should first attempt to reposition the client's arm to alleviate any obstruction (B). After other sources of occlusion are eliminated, the nurse may need to check for a blood return (A), remove the dressing (C), or flush the saline lock (D) and then resume the intermittent infusion. Correct Answer: B
26.In evaluating client care, which action should the nurse take first? A. Determine if the expected outcomes of care were achieved. B. Review the rationales used as the basis of nursing actions. C. Document the care plan goals that were successfully met. D. Prioritize interventions to be added to the client's plan of care.
In evaluating care, the nurse should first determine if the expected outcomes of the plan of care were achieved (A). As indicated, the nurse may then review the initial nursing actions and the rationales for those actions (B), document successful completion of the care plan goals (C), and revise the plan of care (D). Correct Answer: A
2.What activity should the nurse use in the evaluation phase of the nursing process? A. Ask a client to evaluate the nursing care provided. B. Document the nursing care plan in the progress notes. C. Determine whether a client's health problems have been alleviated. D. Examine the effectiveness of nursing interventions toward meeting client outcomes.
In the nursing process, the evaluation component examines the effectiveness of nursing interventions in achieving client outcomes (D). (A) is an evaluation of client satisfaction, not outcomes. (B) is a written record of the plan of care. Although (C) may occur when client outcomes are achieved, evaluation is best determined by attainment of measurable client outcomes. Correct Answer: D
Which related factor should be added to the nursing diagnosis "imbalanced nutrition: more than body requirements" for a patient 105% on the height/weight scale?
Inadequate lifestyle changes in diet and exercise
In preparing a nursing care plan for a client admitted with Guillian Barre Syndrome Which nursing problem has the highest priority?
Ineffective breathing pattern related to ascending paralysis
A client who had abdominal surgery is receiving patient-controlled analgesia (PCA) intravenously to manage pain. The pump is programmed to deliver a basal dose and bolus doses that can be accessed by the client with a lock-out time frame of 10 minutes. The nurse assesses use of the pump during the last hour and identifies that the client attempted to self-administer the analgesic 10 times. Further assessment reveals that the client is experiencing pain still. What should the nurse do first? 1 Monitor the client's pain level for another hour. 2 Determine the integrity of the intravenous delivery system. 3 Reprogram the pump to deliver a bolus dose every eight minutes. 4 Arrange for the client to be evaluated by the health care provider.
Initially, integrity of the intravenous system should be verified to ensure that the client is receiving medication. The intravenous tubing may be kinked or compressed, or the catheter may be dislodged. Continued monitoring will result in the client experiencing unnecessary pain. The nurse may not reprogram the pump to deliver larger or more frequent doses of medication without a health care provider's prescription. The health care provider should be notified if the system is intact and the client is not obtaining relief from pain. The prescription may have to be revised; the basal dose may be increased, the length of the delay may be reduced, or another medication or mode of delivery may be prescribed.
An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct?
Inquire about the source and type of pain
What technique should the school nurse use to assess a group of children with pediculosis capitis (head lice)
Inspect scalp and hair for white....
Which self-care measure is most important for the clinic nurse to emphasize when teaching a client who was recently diagnosed with osteoporosis.
Inspect your home for safety hazards
Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse?
Instruct the client that the stoma will become smaller when the initial swelling diminishes.
A client with metastatic cancer and a very limited prognosis is being discharged. What is the highest priority?
Intake of adequate nutrients will be maintained
Lente, NPH Onset: 2-4 hrs Duration: 16-20 hours Peak: 4-12 hours
Intermediate
ICN =
International Council for Nurses
The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? A. Remain calm with the client and record abnormal results in the chart. B. Notify the medication nurse immediately if the pulse or blood pressure is low. C. Report the results of the vital signs to the nurse. D. Reassure the client that the vital signs are normal.
Interpretation of vital signs is the responsibility of the nurse, so the UAP should report vital sign measurements to the nurse (C). (A, B, and D) require the UAP to interpret the vital signs, which is beyond the scope of the UAP's authority. Correct Answer: C
74.A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath? A. Take measures to promote as much comfort as possible. B. Report any signs of drug addiction to the nurse immediately. C. Wait until the client's pain is gone before assisting with personal care. D. This client's pain will be difficult to manage, since the cause is unknown.
Intractable pain is highly resistant to pain relief measures, so it is important to promote comfort (A) during all activities. A client with intractable pain may develop drug tolerance and dependence, but (B) is inappropriate for a UAP. Since intractable pain is resistant to relief measures, (C) may not be possible. Psychogenic pain (D) is a painful sensation that is perceived but has no known cause. Correct Answer: A
the mother of a one month old boy born brought in for an exam. Which question is important to ask when assessing for hypothyroidism
Is your son sleepy and difficult to feed
An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response?
It is important that you continue your medication while learning to meditate.
A client with metastatic cancer is preparing to make decisions about end of life issues. When the nurse explains a durable power of attorney for health care, which description is accurate?
It will identify someone that can make decisions for your health care if you are in a coma or vegetative state
Fidelity =
Keeping promises; "Integrity"
A male client with CKD is involved in a motor vehicle accident and is brought to the ED with a rapidly hemorraghing leg fracture. Physician has placed a central venous catheter CVC, which equipment should the nurse obtain first?
Lactated Ringers
used to treat ventricular ectopy, ventricular tachycardia, and ventricular fibrillation
Lidocaine
Nurse stops at MVA 6 month old strapped in car seat
Lift care seat out with infant strapped in
The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A. If I exercise at least two times weekly for one hour, I will lower my cholesterol. B. I need to avoid eating proteins, including red meat. C. I will limit my intake of beef to 4 ounces per week. D. My blood level of low density lipoproteins needs to increase.
Limiting saturated fat from animal food sources to no more than 4 ounces per week (C) is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week (A). Red meat and all proteins do not need to be eliminated (B) to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions (2-ounce servings). The low density lipoproteins (D) need to decrease rather than increase. Correct Answer: C
When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?
Loosen the right wrist restraint.
Larger vessel damage
Macroangiopathy
clots build up, accelorates athro sclerosis, which can lead to myocardial infarction
Macrovascualr Angiopathy
Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? A. Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. C. Several areas of red, papular lesions from pinpoint to 0.5 cm in size. D. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter.
Macules are localized flat skin discolorations less than 1 cm in diameter. However, when recording such a finding the nurse should describe the appearance (B) rather than simply naming the condition. (A) identifies vesicles -- fluid filled blisters -- an incorrect description given the symptoms listed. (C) identifies papules -- solid elevated lesions, again not correctly identifying the symptoms. (D) identifies petechiae -- pinpoint red to purple skin discolorations that do not itch, again an incorrect identification. Correct Answer: B
79.When assessing a client with an indwelling urinary catheter, which observation requires the most immediate intervention by the nurse? A. The drainage tubing is secured over the siderail. B. The clamp on the urinary drainage bag is open. C. There are no dependent loops in the drainage tubing. D. The urinary drainage bag is attached to the bed frame.
Maintaining a closed urinary drainage system is important to prevent infection, so the most immediate priority is to close the clamp (B) to reduce the risk for ascending microorganisms. If the drainage tubing is secured over the siderail (A), urine will not be able to flow out of the bladder, so the nurse should next reposition the tubing. (C and D) indicate correct care of the urinary drainage system, so documentation of an intact system is the last intervention needed. Correct Answer: B
When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices?
Many complimentary healing practices can be used in conjunction with conventional practices.
29.A male nurse is assigned to care for a female Muslim client. When the nurse offers to bathe the client, the client requests that a female nurse perform this task. How should the male nurse respond? A. May I ask your daughter to help you with your personal hygiene? B. I will ask one of the female nurses to bathe you. C. A staff member on the next shift will help you. D. I will keep you draped and hand you the supplies as you need them.
Many female Muslim clients are very modest and prefer to receive personal care from another female because of their religious and cultural beliefs. The most culturally sensitive response is for the male nurse to ask a female colleague to perform this task (B). (A and D) are less respectful of the client's cultural and spiritual preferences. (C) delays the client's care. Correct Answer: B
A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What initial action is most important for the nurse to take?
Measure the pulse volume and capillary refill distal to the infiltration.
83.While caring for a child and mother from Cambodia, what action should the nurse implement to accommodate the clients' cultural needs? A. Speak initially with the oldest family member to show respect. B. Realize that Southeast Asians may not take Western medications. C. Ask the husband to step out during the mother's pelvic examination. D. Tell the family that planning health care is provided in private with the client.
Members of the Asian culture have high respect for others, especially those in positions of authority. Extended family members need to be included in the nursing care plan (A). Southeast Asians do not necessarily refuse Western medications (B). Asians also believe that touching strangers is not acceptable, particularly health professionals whom they have not previously known, so the husband should be allowed to remain with his wife during the pelvic exam (C). Provided that the presence of other family members is not harmful to the client's well-being, (D) is not correct. Correct Answer: A
A nurse is reviewing studies to answer a clinical question as part of an evidence-based practice project. The study design determines the level of evidence. Place each methodology in order from the most reliable to the least reliable. Correct 1. Meta-analysis 2. Randomized controlled trial 3. Expert opinion based on scientific principles 4. Cohort study 5. Controlled trial without randomization
Meta-analysis is a synthesis of evidence from associated randomized controlled trials. Meta-analysis is more reliable than a randomized controlled trial. Randomized controlled trials are studies where subjects randomly are assigned to a treatment or control group. A randomized control trial is more reliable than a controlled trial without randomization. Controlled trials without randomization are studies in which subjects are assigned nonrandomly to a treatment or control group. A controlled trial without randomization is more reliable than a cohort study. Cohort studies observe a group to determine the development of an outcome. Expert opinion based on principles is not based on actual evidence; it is relied on when there is no evidence from research. Topics
A client reports fatigue and dyspnea and appears pale. The nurse questions the client about medications currently being taken. In light of the symptoms, which medication causes the nurse to be most concerned? 1 Famotidine (Pepcid) 2 Methyldopa (Aldomet) 3 Ferrous sulfate (Feosol) 4 Levothyroxine (Synthroid)
Methyldopa is associated with acquired hemolytic anemia and should be discontinued to prevent progression and complications. Famotidine will not cause these symptoms; it decreases gastric acid secretion, which will decrease the risk of gastrointestinal bleeding. Ferrous sulfate is an iron supplement to correct, not cause, symptoms of anemia. Levothyroxine is not associated with red blood cell destruction.
Disease in blood vessels, in SMALLER (eyes, diabetic retinapothy)
Microangiopathy
The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client?
Move the chair parallel to the right side of the bed, and stand the client on the right foot.
Is there one specific route to become an RN?
No! There are various educational routes, however BSN programs are becoming the way of the profession and will soon surpass other routes.
When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first?
Note which actions were not implemented.
An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first?
Notify the healthcare provider of the family's request.
What is the ICN definition of nursing?
Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups, & communities, sick or well in all settings.
A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first?
Nutritional history.
The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first?
Observe the appearance of the skin under the ice pack.
71.After a client has been premedicated for surgery with an opioid analgesic, the nurse discovers that the operative permit has not been signed. What action should the nurse implement? A. Notify the surgeon that the consent form has not been signed. B. Read the consent form to the client before witnessing the client's signature. C. Determine if the client's spouse is willing to sign the consent form. D. Administer an opioid antagonist prior to obtaining the client's signature.
Once a client has been premedicated for surgery with any type of sedative, legal informed consent is not possible, so the nurse must notify the surgeon (A). (B, C, and D) are not legally viable options for ensuring informed consent. Correct Answer: A
Once digested, 100% of carbohydrates are converted to glucose. However, approximately 40% of protein foods are also converted to glucose, but this has minimal effect on blood glucose levels
Once digested, what percentage of carbohydrates is converted to glucose
Critical thinking involves
Open-mindedness, continual inquiry, and perseverance, combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant
PES format:
P = problem E = etiology or related factor S= symptoms or defining characteristics
The P wave depicts atrial depolarization, or spread of the electrical impulse from the sinoatrial node through the atria.
P Wave
"It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node." Explanation: The PR interval is measured from the beginning of the P wave to the beginning of the QRS complex and represents the time needed for sinus node stimulation, atrial depolarization, and conduction through the AV node before ventricular depolarization. In a normal heart the impulses do not travel backward. The PR interval does not include the time it take to travel through the Purkinje fibers
P-R interval
The PR interval represents spread of the impulse through the interatrial and internodal fibers, atrioventricular node, bundle of His, and Purkinje fibers.
PR Interval
A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What initial action is most important for the nurse to take? A. Ask about any past history of drug abuse or addiction. B. Measure the pulse volume and capillary refill distal to the infiltration. C. Compress the infiltrated tissue to measure the degree of edema. D. Evaluate the extent of ecchymosis over the forearm area.
Pain and diminished pulse volume (B) are signs of compartment syndrome, which can progress to complete loss of the peripheral pulse in the extremity. Compartment syndrome occurs when external pressure (usually from a cast), or internal pressure (usually from subcutaneous infused fluid), exceeds capillary perfusion pressure resulting in decreased blood flow to the extremity. (A) should not be pursued until physical causes of the pain are ruled out. (C) is of less priority than determining the effects of the edema on circulation and nerve function. Further assessment of the client's ecchymosis can be delayed until the signs of edema and compression that suggest compartment syndrome have been examined (D). Correct Answer: B
a male client had a TURP today has a continuous bladder irrigation. The client requests pain meds for abdominal pain 9/10. What action should the nurse take?
Palpate his abdomen and check his UO
43.The nurse is digitally removing a fecal impaction for a client. The nurse should stop the procedure and take corrective action if which client reaction is noted? A. Temperature increases from 98.8° to 99.0° F. B. Pulse rate decreases from 78 to 52 beats/min. C. Respiratory rate increases from 16 to 24 breaths/min. D. Blood pressure increases from 110/84 to 118/88 mm/Hg.
Parasympathetic reaction can occur as a result of digital stimulation of the anal sphincter, which should be stopped if the client experiences a vagal response, such as bradycardia (B). (A, C, and D) do not warrant stopping the procedure. Correct Answer: B
90.The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the nurse take next? A. Raise the bed to a comfortable working level. B. Bend the client's knee. C. Move the knee toward the chest as far as it will go. D. Cradle the client's heel.
Passive ROM exercise for the hip and knee is provided by supporting the joints of the knee and ankle (D) and gently moving the limb in a slow, smooth, firm but gentle manner. (A) should be done before the exercises are begun to prevent injury to the nurse and client. (B) is carried out after both joints are supported. After the knee is bent, then the knee is moved toward the chest to the point of resistance (C) two or three times. Correct Answer: D
4.What action by the nurse demonstrates culturally sensitive care? A. Asks permission before touching a client. B. Avoids questions about male-female relationships. C. Explains the differences between Western medical care and cultural folk remedies. D. Applies knowledge of a cultural group unless a client embraces Western customs.
Physical contact, such as touching the head, in some cultures is a sign of respect, whereas in others, it is strictly forbidden. So asking permission before touching a client (A) demonstrates culturally sensitive care. (B, C, and D) do not demonstrate cultural awareness. Correct Answer: A
84.Which client care requires the nurse to wear barrier gloves as required by the protocol for Standard Precautions? A. Removing the empty food tray from a client with a urinary catheter. B. Washing and combing the hair of a client with a fractured leg in traction. C. Administering oral medications to a cooperative client with a wound infection. D. Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.
Possible contact with body secretions, excretions, or broken skin is an indication for wearing barrier (nonsterile) gloves. Emptying a urine drainage bag requires the use of gloves (D). (A, B, and C) do not require gloves. Correct Answer: D
Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? A. Reassure the client that he will become accustomed to the stoma appearance in time. B. Instruct the client that the stoma will become smaller when the initial swelling diminishes. C. Offer to contact a member of the local ostomy support group to help him with his concerns. D. Encourage the client to handle the stoma equipment to gain confidence with the procedure.
Postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when the swelling is diminished (B). This will help reduce the client's anxiety and promote acceptance of the colostomy. (A) does not provide helpful teaching or support. (C) is a useful action, and may be taken after the nurse provides pertinent teaching. The client is not yet demonstrating readiness to learn colostomy care (D). Correct Answer: B
64.A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal insufficiency and hypertension, who gained 3 pounds in the last month. The nurse determines that the client has been noncompliant with the diet, based on which report from the 24-hour dietary recall? (Select all that apply.) A. Snack of potato chips, and diet soda. B. Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee. C. Breakfast of eggs, bacon, toast, and coffee. D. Dinner of vegetable lasagna, tossed salad, sherbet, and iced tea. E. Bedtime snack of crackers and milk.
Potato chips (A) are high in sodium. Tuna (B) is high in protein. Bacon (C) and crackers (E) are high in sodium. Only (D) is a meal that is in compliance with a low sodium, low protein diet. Correct Answer: A, B, C, E
Alternative therapy measures have become increasingly accepted within the past decade, especially in the relief of pain. Which methods qualify as alternative therapies for pain? Select all that apply. 1 Prayer 2 Hypnosis 3 Medication 4 Aromatherapy 5 Guided imagery
Prayer is an alternative therapy that may relax the client and provide strength, solace, or acceptance. The relief of pain through hypnosis is based on suggestion; also, it focuses attention away from the pain. Some clients learn to hypnotize themselves. Aromatherapy can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Guided imagery can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Analgesics, both opioid and nonopioid, long have been part of the standard medical regimen for pain relief, so they are not considered an alternative therapy.
What is the purpose of the code of ethics for nurses?
Provide a powerful statement of the ethical values, obligations, and duties of every individual who enters the nursing profession. The code of ethics serves as the nonnegotiable ethical standard of practice.
69.On the third postoperative day following thoracic surgery, a client reports feeling constipated. Which intervention should the nurse implement to promote bowel elimination? A. Remind the client to turn every two hours while lying in bed. B. Provide warm prune juice before the client goes to bed at night. C. Teach the client to splint the incision while walking to the bathroom. D. Administer an analgesic before the client attempts to defecate.
Prune juice is a natural laxative that stimulates peristalsis, and warming the prune juice (B) facilitates peristalsis. (A) is also helpful in promoting peristalsis but is less likely to relieve the client's constipation. (C) reduces discomfort during ambulation, but will not help relieve the client's constipation. Defecation is not painful following most surgeries, and many analgesics used postoperatively cause constipation, so (D) is contraindicated. Correct Answer: B
The nurse is assessing an older client and determines that the client's left eyelid droops covering more iris than the right eyelid. Which description should the nurse use to document this finding?
Ptosis of the left eye
The QRS complex represents ventricular depolarization.
QRS Complex
QSEN =
Quality and safety education for nurses
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement?
Reassess the client's blood pressure using a larger cuff.
In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly A. is to be expected, and progresses with age. B. often follows relocation to new surroundings. C. is a result of irreversible brain pathology. D. can be prevented with adequate sleep.
Relocation (B) often results in confusion among elderly clients--moving is stressful for anyone. (A) is a stereotypical judgment. Stress in the elderly often manifests itself as confusion, so (C) is wrong. Adequate sleep is not a prevention (D) for confusion. Correct Answer: B
Nurse observes male HCP viewing sister's med record on computer?
Remind HCP that only the treatment team should view the record
Nurse is preparing a male client for a bilateral adrenalectomy. Whhich info in preop teaching?
Replacement therapy with corticosteroids will be needed for the rest of his life.
The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP?
Report the results of the vital signs to the nurse.
An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP?
Reposition in a Sim's position with the client's weight on the anterior ilium.
A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first?
Reposition the client on her side
A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take?
Request and document the name of the certified translator.
RACE
Rescue Alarm Contain Extinguish --> PASS
Human Dignity =
Respect for inherent worth and uniqueness of individuals and populations
Autonomy in bioethics =
Respect rights of patients to make health care decisions
Nurses have a bill of rights that:
Results in advocacy on behalf of the nursing profession. Empowers nurses. Improves workplace. Ensures nurses' ability to provide safe, quality care. Allows them to freely advocate for themselves and their patients, without fear of retribution.
The SMART approach to writing goals stands for:
S specific M measurable A attainable R realistic T timed
pulse regulated by
SA node
51.The home health nurse visits an elderly female client who had a brain attack three months ago and is now able to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications for this client's care? A. The husband, who is the caregiver, begins to weep when the nurse asks how he is doing. B. The client tells the nurse that she does not have much of an appetite today. C. The nurse notes that there are numerous scatter rugs throughout the house. D. The client's pulse rate is 10 beats higher than it was at the last visit one week ago.
Scatter rugs (C) pose a safety hazard because the client can trip on them when ambulating, so this finding has the greatest significance in planning this client's care. Psychological support of the caregiver (A) is a less acute need than that of client safety. The nurse needs to obtain more information about (B), but this is not a safety issue. (D) is not a significant increase, and additional assessment might provide information about the reason for the increase (anxiety, exercise, etc.). Correct Answer: C
The nurse is developing a teaching plan for a client who was recently diagnosed with pernicious anemia and requires B12 vitamin replacement therapy. Which precaution is most important for the nurse to include in the patient's plan of care
Schedule daily rest periods to minimize fatigue
46.A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicates the client's protein status for the longest length of time? A. Transferrin. B. Prealbumin. C. Serum albumin. D. Urine urea nitrogen.
Serum albumin has a long half-life and is the best long-term indicator of the body's entry into a catabolic state following protein depletion from malnutrition or stress of chronic illness (C). While (A) is a good indicator of iron-binding capacity in a healthy adult, it is an unreliable measure in the client with a chronic illness. (B) has a short half-life, and is a sensitive indicator of recent catabolic changes, but it is not as effective as (C) in indicating long-term protein depletion. While (D) is a good indicator of a negative nitrogen balance, it is not as good an indicator of long-term protein catabolism as is (C). Correct Answer: C
The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions?
Skim milk, turkey salad, roll, and vanilla ice cream.
The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? A. Tossed salad, low-sodium dressing, bacon and tomato sandwich. B. New England clam chowder, no-salt crackers, fresh fruit salad. C. Skim milk, turkey salad, roll, and vanilla ice cream. D. Macaroni and cheese, diet Coke, a slice of cherry pie.
Skim milk, turkey, bread, and ice cream (C), while containing some sodium, are considered low-sodium foods. Bacon (A), canned soups (B), especially those with seafood, hard cheeses, macaroni, and most diet drinks (D) are very high in sodium. Correct Answer: C
39.When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum "tents" when gently pinched. Which action should the nurse implement? A. Confirm the finding by further assessing the client for jugular vein distention. B. Offer the client high protein snacks between regularly scheduled mealtimes. C. Continue the planned nursing interventions to restore the client's fluid volume. D. Change the plan of care to include a nursing diagnosis of impaired skin integrity.
Skin turgor is assessed by pinching the skin and observing for tenting. This finding confirms the diagnosis of fluid volume deficit, so the nurse should continue interventions to restore the client's fluid volume (C). Jugular vein distention (A) is a sign of fluid volume overload. High protein snacks (B) will not resolve the fluid volume deficit. Changes in the client's skin integrity are not evident (D). Correct Answer: C
Staging of Pressure Ulcers
Stage 1: intact skin, area of persistent redness
A client is brought into the ED following sudden cardiac arrest. A full code is started. Five minutes later the family arrives with a durable power of attorney signed by the client requesting that no extraordinary measures be taken, including intubation to save the client's life. What action should the nurse take?
Stop the code immediately.
The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? A. Encourage the client to cough to help loosen secretions. B. Advise the client to increase the intake of oral fluids. C. Rotate the suction catheter to obtain any remaining secretions. D. Re-oxygenate the client before attempting to suction again.
Suctioning should not be continued for longer than ten to fifteen seconds, since the client's oxygenation is compromised during this time (D). (A, B, and C) may be performed after the client is re-oxygenated and additional suctioning is performed. Correct Answer: D
A client with an overactive bladder receives a prescription Oxybutynin (Ditropan) an anticholinergic agent. What action should the nurse include in the teaching plan?
Sugar free hard candies may relieve dry mouth
The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A. Infuse normal saline at a keep vein open rate. B. Discontinue the IV and flush the port with heparin. C. Infuse 10 percent dextrose and water at 54 ml/hr. D. Obtain a stat blood glucose level and notify the healthcare provider.
TPN is discontinued gradually to allow the client to adjust to decreased levels of glucose. Administering 10% dextrose in water at the prescribed rate (C) will keep the client from experiencing hypoglycemia until the next TPN solution is available. The client could experience a hypoglycemic reaction if the current level of glucose (A) is not maintained or if the TPN is discontinued abruptly (B). There is no reason to obtain a stat blood glucose level (D) and the healthcare provider cannot do anything about this situation. Correct Answer: C
Because a client with Bells' Palsy is at risk for impaired nutrition which action should the nurse include in the client's plan of care
Teach client to chew food on the unaffected side of the face
A nurse takes a female client to the examination room and asks her to remove her undergarments. The woman explains that she cannot due to religious reasons. How should the nurse respond?
Tell me about your undergarments so we can discuss how we can have your examination comfortably
49.When caring for an immobile client, what nursing diagnosis has the highest priority? A. Risk for fluid volume deficit. B. Impaired gas exchange. C. Risk for impaired skin integrity. D. Altered tissue perfusion.
The ABCs of caring for clients are airway, breathing, and circulation. Impaired gas exchange (B) implies that the client is having trouble with breathing, which has the highest priority of the nursing diagnoses listed. Though an immobilized client presents a multitude of nursing care challenges, (A, C, and D) do not have the priority of (B). Correct Answer: B
The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next? A. Clamp the tube for 20 minutes. B. Flush the tube with water. C. Administer the medications as prescribed. D. Crush the tablets and dissolve in sterile water.
The NGT should be flushed before, after and in between each medication administered (B). Once all medications are administered, the NGT should be clamped for 20 minutes (A). (C and D) may be implemented only after the tubing has been flushed. Correct Answer: B
65.What intervention should the nurse include in the plan of care for a client who is being treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency? A. Check capillary refill of toes on lower extremity with Unna's paste boot. B. Apply dressing to wound area before applying the Unna's paste boot. C. Wrap the leg from the knee down towards the foot. D. Remove the Unna's paste boot q8h to assess wound healing.
The Unna's paste boot becomes rigid after it dries, so it is important to check distally for adequate circulation (A). Kerlix is often wrapped around the outside of the boot and an ace bandage may be used to cover both, but no bandage should be put under it (B). The Unna's paste boot should be applied from the foot and wrapped towards the knee (C). The Unna's paste boot acts as a sterile dressing, and should not be removed q8h. Weekly removal is reasonable (D). Correct Answer: A
Competency =
The ability to do something correctly, efficiently, and successfully.
The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute? A. 80 B. 8 C. 21 D. 25
The accepted formula for figuring drops per minute is: amount to be infused in one hour × drop factor/time for infusion (min)= drops per minute. Using this formula: 1,000/8 hours = 125 ml/ hour 125 × 10 (drip factor) = 1,250 drops in one hour. 1,250/ 60 (number of minutes in one hour) = 20.8 or 21 gtt/min (C). Correct Answer: C
25.Which nursing intervention is most beneficial in reducing the risk of urosepsis in a hospitalized client with an indwelling urinary catheter? A. Ensure that the client's perineal area is cleansed twice a day. B. Maintain accurate documentation of the fluid intake and output. C. Encourage frequent ambulation if allowed or regular turning if on bedrest. D. Obtain a prescription for removal of the catheter as soon as possible.
The best intervention to reduce the risk for urosepsis (spread of an infectious agent from the urinary tract to systemic circulation) is removal of the urinary catheter as quickly as possible (D). (A, B, and C) are helpful to reduce the risk of infection, but are of less priority than (D) in reducing the risk of urosepsis. Correct Answer: D
When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the A. Arms. B. Upper torso. C. Head. D. Feet.
The center of gravity for adults is the hips. However, as the person grows older, a stooped posture is common because of the changes from osteoporosis and normal bone degeneration, and the knees, hips, and elbows flex. This stooped posture results in the upper torso (B) becoming the center of gravity for older persons. Although (A) is a part, or an extension of the upper torso, this is not the best and most complete answer. Correct Answer: B
A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? A. demonstrates loss of remote memory. B. exhibits expressive dysphasia. C. has a diminished attention span. D. is disoriented to place and time.
The client is exhibiting disorientation (D). (A) refers to memory of the distant past. The client is able to express himself without difficulty (B), and does not demonstrate a diminished attention span (C). Correct Answer: D
The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? A. Immediately after exhalation. B. During the inhalation. C. At the end of three inhalations. D. Immediately after inhalation.
The client should be instructed to deliver the medication during the last part of inhalation (B). After the medication is delivered, the client should remove the mouthpiece, keeping his/her lips closed and breath held for several seconds to allow for distribution of the medication. The client should not deliver the dose as stated in (A or D), and should deliver no more than two inhalations at a time (C). Correct Answer: B
An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? A. Prone. B. Fowler's. C. Sims'. D. Supine.
The client should be positioned in a semi-sitting (Fowler's) (B) position during feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into the stomach through an incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client. In (A and/or C), the client is placed on the abdomen, an unsafe position for feeding. Placing the client in (D) increases the risk of aspiration. Correct Answer: B
An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The nurse knows that the best position for this client during administration of the feedings is A. prone. B. Fowler's. C. Sims'. D. supine.
The client should be positioned in a semi-sitting or Fowler's (B) position during feeding, in order to decrease the chance of aspiration. A gastrostomy tube, often referred to as a PEG tube, is inserted directly into the stomach through an incision in the abdomen and is used when long-term tube feedings are needed. In (A and/or C) positions, the client would be lying on his abdomen and on the tubing. In (D), the client would be lying flat on his back which would increase the chance of aspiration. Correct Answer: B
57.A signed consent form indicated a client should have an electromyogram, but a myelogram was performed instead. Though the myelogram revealed the cause of the client's back pain, which was subsequently treated, the client filed a lawsuit against the nurse and healthcare provider for performing the incorrect procedure. The court is likely to rule in favor of the plaintiff because these events represent what infraction? A. A quasi-intentional tort because a similar mistake can happen to anyone. B. Failure to respect client autonomy to choose based on intentional tort law. C. Assault and battery with deliberate intent to deviate from the consent form. D. An unintentional tort because the client benefited from having the myelogram.
The client was not properly informed of the procedure, and failure to obtain informed consent constitutes assault and battery (C). (A) is injury to economics and dignity, such as invasion of privacy or defamation of character. This is not an incident of failure to respect the client's autonomy (B). An unintentional tort (D) is an act in which the outcome was not expected, such as negligence or malpractice. Correct Answer: C
The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan? A. Avoid any types of sprays, powders, and perfumes. B. Wearing a mask while cleaning will not help to avoid allergens. C. Purchase any type of clothing, but be sure it is washed before wearing it. D. Pollen count is related to hay fever, not to allergens.
The client with allergies should be instructed to reduce any exposure to pollen, dust, fumes, odors, sprays, powders, and perfumes (A). The client should be encouraged to wear a mask when working around dust or pollen (B). Clients with allergies should avoid any clothing that causes itching; washing clothes will not prevent an allergic reaction to some fabrics (C). Pollen count is related to allergens (D), and the client should be instructed to stay indoors when the pollen count is high. Correct Answer: A
Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status? A. Chocolate pudding. B. Graham crackers. C. Sugar free gelatin. D. Apple slices.
The client with myasthenia gravis is at high risk for altered nutrition because of fatigue and muscle weakness resulting in dysphagia. Snacks that are semisolid, such as pudding (A) are easy to swallow and require minimal chewing effort, and provide calories and protein. (C) does not provide any nutritional value. (B and D) require energy to chew and are more difficult to swallow than pudding. Correct Answer: A
A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan? A. In 8 weeks you will be able to bend at the waist to reach items on the floor. B. Place a pillow between your knees while lying in bed to prevent hip dislocation. C. It is safe to use a walker to get out of bed, but you need assistance when walking. D. Take pain medication 30 minutes after your physical therapy sessions.
The client's affected hip joint following a hemiarthroplasty (partial hip replacement) is at risk of dislocation for 6 months to a year following the procedure. Hip precautions to prevent dislocation include placing a pillow between the knees to maintain abduction of the hips (B). Clients should be instructed to avoid bending at the waist (A), to seek assistance for both standing and walking until they are stable on a walker or cane (C), and to take pain medication 20 to 30 minutes prior to physical therapy sessions, rather than waiting until the pain level is high after their therapy. Correct Answer: B
15.A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite around-the-clock use of oxycodone (Percodan) and amitriptyline (Elavil) for pain control at home. During the admission assessment, which information is most important for the nurse to obtain? A. Sensory pattern, area, intensity, and nature of the pain. B. Trigger points identified by palpation and manual pressure of painful areas. C. Schedule and total dosages of drugs currently used for breakthrough pain. D. Sympathetic responses consistent with onset of acute pain.
The components of every pain assessment should include sensory patterns, area, intensity, and nature (PAIN) of the pain (A) and are essential in identifying appropriate therapy for the client's specific type and severity of pain, which may indicate the onset of disease progression or complications. Triggers (B), current drug usage (C), and sympathetic responses (D), such as tachycardia, diaphoresis, and elevated blood pressure, are important, but should be obtained after focusing on (A). Correct Answer: A
14.A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments. What information should the nurse offer the client about general use of herbal supplements? A. Most herbs are toxic or carcinogenic and should be used only when proven effective. B. There is no evidence that herbs are safe or effective as compared to conventional supplements in maintaining health. C. Herbs should be obtained from manufacturers with a history of quality control of their supplements. D. Herbal therapies may mask the symptoms of serious disease, so frequent medical evaluation is required during use.
The current availability of many herbal supplements lacks federal regulation, research, control and standardization in the manufacture of its purity and dose. Manufacturers that provide evidence of quality control (C), such as labeling that contains scientific generic name, name and address of the manufacturer, batch or lot number, date of manufacture, and expiration date, is the best information to provide. (A, B, and D) are misleading. Correct Answer: C
11.Which statement best describes durable power of attorney for health care? A. The client signs a document that designates another person to make legally binding healthcare decisions if client is unable to do so. B. The healthcare decisions made by another person designated by the client are not legally binding. C. Instructions about actions to be taken in the event of a client's terminal or irreversible condition are not legally binding. D. Directions regarding care in the event of a terminal or irreversible condition must be documented to ensure that they are legally binding.
The durable power of attorney is a legal document or a form of advance directive that designates another person to voice healthcare decisions when the client is unable to do so. A durable power of attorney for health directives is legally binding (A). (B, C and D) do not include the legal parameters that must be determined by the client in the event the client is unable to make a healthcare decision, which can be changed by the client at any time. Correct Answer: A
The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? A. Observe the appearance of the skin under the ice pack. B. Instruct the client regarding the need for the covering. C. Reapply the covering after filling with fresh ice. D. Ask the client how long the ice was applied to the skin.
The first action taken by the nurse should be to assess the skin for any possible thermal injury (A). If no injury to the skin has occurred, the nurse can take the other actions (B, C, and D) as needed. Correct Answer: A
3.Which statement is an example of a correctly written nursing diagnosis statement? A. Altered tissue perfusion related to congestive heart failure. B. Altered urinary elimination related to urinary tract infection. C. Risk for impaired tissue integrity related to client's refusal to turn. D. Ineffective coping related to response to positive biopsy test results.
The first part of the nursing diagnosis statement is the diagnostic label and is followed by related to the cause, which should direct the nurse to the appropriate interventions. (D) best fits this criteria. (A and B) contain a medical diagnosis. (C) includes an observable cause, but (D) focuses on the client's response, which the nurse can provide support, reflection, and dialogue. Correct Answer: D
An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes. B. The nurse assigned to care for the client who was at lunch at the time of the fall. C. The nurse who transferred the client to the chair when the fall occurred. D. The charge nurse who completed rounds 30 minutes before the fall occurred.
The four elements of malpractice are: breach of duty owed, failure to adhere to the recognized standard of care, direct causation of injury, and evidence of actual injury. The hip fracture is the actual injury and the standard of care was "frequent monitoring." (C) implies that duty was owed and the injury occurred while the nurse was in charge of the client's care. There is no evidence of negligence in (A, B, and D). Correct Answer: C
The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? A. Thalamus. B. Hypothalamus. C. Frontal lobe. D. Parietal lobe.
The frontal lobe (C) of the cerebrum controls higher mental activities, such as memory, intellect, language, emotions, and personality. (A) is an afferent relay center in the brain that directs impulses to the cerebral cortex. (B) regulates body temperature, appetite, maintains a wakeful state, and links higher centers with the autonomic nervous and endocrine systems, such as the pituitary. (D) is the location of sensory and motor functions. Correct Answer: C
During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? A. Adequate venous blood flow to the lower extremities. B. Estimated amount of body fat by an underarm skinfold. C. Degree of flexion and extension of the client's knee joint. D. Change in the circumference of the joint in centimeters.
The goniometer is a two-piece ruler that is jointed in the middle with a protractor-type measuring device that is placed over a joint as the individual extends or flexes the joint to measure the degrees of flexion and extension on the protractor (C). A doppler is used to measure blood flow (A). Calipers are used to measure body fat (B). A tape measure is used to measure circumference of body parts (D). Correct Answer: C
A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first? A. Irrigate the nasogastric tube with sterile normal saline. B. Reposition the client on her side. C. Advance the nasogastric tube an additional five centimeters. D. Administer an intravenous antiemetic prescribed for PRN use.
The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention, (B), should be attempted first, followed by (A and C), unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require an antiemetic (D). Correct Answer: B
An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? A. Position the client on the right side of the bed in reverse Trendelenburg. B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C. Reposition in a Sim's position with the client's weight on the anterior ilium. D. Raise the side rails on both sides of the bed and elevate the bed to waist level.
The left sided Sims' position allows the enema solution to follow the anatomical course of the intestines and allows the best overall results, so the UAP should reposition the client in the Sims' position, which distributes the client's weight to the anterior ilium (C). (A) is inaccurate. (B and D) should be implemented once the client is positioned. Correct Answer: C
32.A male client has a nursing diagnosis of "spiritual distress." What intervention is best for the nurse to implement when caring for this client? A. Use distraction techniques during times of spiritual stress and crisis. B. Reassure the client that his faith will be regained with time and support. C. Consult with the staff chaplain and ask that the chaplain visit with the client. D. Use reflective listening techniques when the client expresses spiritual doubts.
The most beneficial nursing intervention is to use nonjudgmental reflective listening techniques, to allow the client to feel comfortable expressing his concerns (D). (A and B) are not therapeutic. The client should be consulted before implementing (C). Correct Answer: D
A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? A. Give an around-the-clock schedule for administration of analgesics. B. Administer analgesic medication as needed when the pain is severe. C. Provide medication to keep the client sedated and unaware of stimuli. D. Offer a medication-free period so that the client can do daily activities.
The most effective management of pain is achieved using an around-the-clock schedule that provides analgesic medications on a regular basis (A) and in a timely manner. Analgesics are less effective if pain persists until it is severe, so an analgesic medication should be administered before the client's pain peaks (B). Providing comfort is a priority for the client who is dying, but sedation that impairs the client's ability to interact and experience the time before life ends should be minimized (C). Offering a medication-free period allows the serum drug level to fall, which is not an effective method to manage chronic pain (D). Correct Answer: A
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement? A. Tell the UAP to use a larger cuff at the next scheduled assessment. B. Reassess the client's blood pressure using a larger cuff. C. Have the unit educator review this procedure with the UAPs. D. Teach the UAP the correct technique for assessing blood pressure.
The most important action is to ensure that an accurate BP reading is obtained. The nurse should reassess the BP with the correct size cuff (B). Reassessment should not be postponed (A). Though (C and D) are likely indicated, these actions do not have the priority of (B). Correct Answer: B
6.Which technique is most important for the nurse to implement when performing a physical assessment? A. A head-to-toe approach. B. The medical systems model. C. A consistent, systematic approach. D. An approach related to a nursing model.
The most important factor in performing a physical assessment is following a consistent and systematic technique (C) each time an assessment is performed to minimize variation in sequence which may increase the likelihood of omitting a step or exam of an isolated area. The method of completing a physical assessment (A, B, and D) may be at the discretion of the examiner, but a consistent sequence by the examiner provides a reliable method to ensure thorough review of the clients' history, complaints, or body systems. Correct Answer: C
An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? A. Be sure to have a complete physical examination before beginning your planned exercise program. B. Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more. C. Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class. D. Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation.
The most important teaching is (A), so that the client will not begin a dangerous level of exercise when he is not sufficiently fit. This might result in chest pain, a heart attack, or stroke. (B, C, and D) are important instructions, but are of less priority than (A). Correct Answer: A
What is provision 8 of the code of ethics?
The nurse collaborate with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.
What is provision 4 of the code of ethics?
The nurse has authority, accountability, and responsibility for nursing practice' makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care.
27.Prior to administering a newly prescribed medication to a client, the nurse reviews the adverse effects of the medication listed in a drug reference guide and determines the priority risks to the client. While performing this action, the nurse is engaged in which step of the nursing process? A. Assessment. B. Analysis. C. Implementation. D. Evaluation.
The nurse is analyzing (B) data to establish an individualized nursing diagnosis, such as, "Risk for injury related to side effects of drugs." This analysis is based on assessment (A) and guides the planning and implementation (C) of care, such as the decision to monitor the client frequently. (D) provides the nurse with information about the effectiveness of the plan of care. Correct Answer: B
Desmopressin Why?
The nurse is caring for a client with diabetes insipidus. The nurse should anticipate the administration of:
What is provision 5 of the code of ethics?
The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character, and integrity, maintain competence, and continue personal and professional growth.
What is provision 1 of the code of ethics?
The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.
34.The nurse overhears the healthcare provider explaining to the client that the tumor removed was non-malignant and that the client will be fine. However, the nurse has read in the pathology report that the tumor was malignant and that there is extensive metastasis. Who should the nurse consult with first regarding the situation? A. Healthcare provider. B. Client's family. C. Case manager. D. Chief of staff.
The nurse should address the healthcare provider with the written report and discuss why he/she did not tell the client the truth--this may be at the family's request (A). (B, C, and D) may be indicated, but first the nurse should confer with the healthcare provider to obtain all needed information. Correct Answer: A
48.How should the nurse handle linens that are soiled with incontinent feces? A. Put the soiled linens in an isolation bag, then place it in the dirty linen hamper. B. Place an isolation hamper in the client's room and discard the linens in it. C. Place the soiled linens in a pillow case and deposit them in the dirty linen hamper. D. Ask the housekeeping staff to pick up the soiled linen from the dirty utility room.
The nurse should be careful to keep the soiled linens from contaminating the fresh linens, and should handle the soiled linens like any other dirty linen (C). (A, B, and D) are not indicated. Correct Answer: C
58.A nurse observes a student nurse taking a copy of a client's medication administration record. When questioned, the student states, Another student is scheduled to administer medications for this client tomorrow, so I am going to make a copy to help my friend prepare for tomorrow's clinical. What response should the nurse provide first? A. Ask the nursing supervisor to meet with the students. B. Notify the student's clinical instructor of the situation. C. Ask the student if permission was obtained from the client. D. Explain that the records are hospital property and may not be removed.
The nurse should deal with the issue immediately and explain that a client's records are the property of the hospital and cannot be removed (D), even with the client's permission (C). Next, the clinical instructor should be notified (B)so that all students can be educated regarding copying and removing clinical records from the healthcare agency. The nursing supervisor (A) should also be alerted to ensure appropriate supervision of students as well as protection of client information. Correct Answer: D
81.The nurse is completing the plan of care for a client who is admitted for benign prostatic hypertrophy. Which data should the nurse document as a subjective findings? A. Complains of inability to empty bladder. B. Temperature of 99.8° F and pulse of 108. C. Post-voided residual volume of 750 ml. D. Specimen collection for culture and sensitivity.
The nurse should document the client's complaints (A) as subjective data--symptoms only the client can describe. (B) should be documented as objective data, which is collected via the nurse's observation. (C and D) are documented as intervention results. Correct Answer: A
35.A single mother of two teenagers, ages 16 and 18, was just told that she has advanced cancer. She is devastated by the news, and expresses her concern about who will care for her children. Which statement by the nurse is likely to be most helpful at this time? A. Your children are old enough to help you make decisions about their futures. B. The social worker can tell you about placement alternatives for your children. C. Tell me what you would like to see happen with your children in the future. D. You have just received bad news, and you need some time to adjust to it.
The nurse should first assess what the client desires (C). (A) is somewhat judgmental and attempts to solve the problem for the client without eliciting the client's feelings. Though a referral to the social worker (B) may be indicated, the nurse should first offer support. Time is likely to help the client cope with this news (D), but the nurse should first provide support and assess what the client wants to see happen with her children. Correct Answer: C
An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A. Reaffirm the client's desire for no resuscitative efforts. B. Transfer the client to a hospice inpatient facility. C. Prepare the family for the client's impending death. D. Notify the healthcare provider of the family's request.
The nurse should first communicate with the healthcare provider (D). Hospice care is provided for clients with a limited life expectancy, which must be identified by the healthcare provider. (A) is not necessary at this time. Once the healthcare provider supports the transfer to hospice care, the nurse can collaborate with the hospice staff and healthcare provider to determine when (B and C) should be implemented. Correct Answer: D
59.An older female client with rheumatoid arthritis is complaining of severe joint pain that is caused by the weight of the linen on her legs. What action should the nurse implement first? A. Apply flannel pajamas to provide warmth. B. Administer a PRN dose of ibuprofen. C. Perform range of motion exercises in a warm tub. D. Drape the sheets over the footboard of the bed.
The nurse should first provide an immediate comfort measure to address the client's complaint about the linens and drape the linens over the footboard of the bed (D) instead of tucking them under the mattress, which can add pressure perceived by the client as the source of her pain. (A, B, and C) may be components of the client's plan of care, but the nurse should first address the client's complaint. Correct Answer: D
28.The nurses determines a client's IV solution is infusing at 250 ml/hr. The prescribed rate is 125 ml/hr. What action should the nurse take first? A. Determine when the IV solution was started. B. Slow the IV infusion to keep vein open rate. C. Assess the IV insertion site for swelling. D. Report the finding to the healthcare provider.
The nurse should first slow the IV flow rate to keep vein open (KVO) rate (B) to prevent further risk of fluid volume overload, then gather additional assessment data, such as when the IV solution was started (A) and the appearance of the IV insertion site (C) before contacting the healthcare provider (D) for further instructions. Correct Answer: B
72.A client who has been on bedrest for several days now has a prescription to progress activity as tolerated. When the nurse assists the client out of bed for the first time, the client becomes dizzy. What action should the nurse implement? A. Encourage the client to take several slow, deep breaths while ambulating. B. Help the client to remain standing by the bedside until the dizziness is relieved. C. Instruct the client to remain on bedrest until the healthcare provider is contacted. D. Advise the client to sit on the side of the bed for a few minutes before standing again.
The nurse should implement (D), because orthostatic hypotension is a common result of immobilization, causing the client to feel dizzy when first getting out of bed following a period of bedrest. To prevent this problem, it is helpful to have the body acclimate to a standing position by sitting upright for a short period (D) before rising to a standing position. (A) is unlikely to alleviate the dizziness. (B) may result in a loss of consciousness. (C) is not indicated and will increase the potential for complications associated with prolonged immobility. Correct Answer: D
20.The nurse is preparing a male client who has an indwelling catheter and an IV infusion to ambulate from the bed to a chair for the first time following abdominal surgery. What action(s) should the nurse implement prior to assisting the client to the chair? (Select all that apply.) A. Pre-medicate the client with an analgesic. B. Inform the client of the plan for moving to the chair. C. Obtain and place a portable commode by the bed. D. Ask the client to push the IV pole to the chair. E. Clamp the indwelling catheter. F. Assess the client's blood pressure.
The nurse should plan to implement (A, B, D, and F). Pre-medicating the client with an analgesic (A) reduces the client's pain during mobilization and maximizes compliance. To ensure the client's cooperation and promote independence, the nurse should inform the client about the plan for moving to the chair (B) and encourage the client to participate by pushing the IV pole when walking to the chair (D). The nurse should assess the client's blood pressure (F) prior to mobilization, which can cause orthostatic hypotension. (C and E) are not indicated. Correct Answer: A, B, D, F
The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? A. The client voluntarily signed the form. B. The client fully understands the procedure. C. The client agrees with the procedure to be done. D. The client authorizes continued treatment.
The nurse signs the consent form to witness that the client voluntarily signs the consent (A), that the client's signature is authentic, and that the client is otherwise competent to give consent. It is the healthcare provider's responsibility to ensure the client fully understands the procedure (B). The nurse's signature does not indicate (C or D). Correct Answer: A
68.Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse implement in response to this situation? A. Notify the charge nurse that a medication error occurred. B. Submit a medication variance report to the supervisor. C. Document the events that occurred in the nurses' notes. D. Discard the original medication administration record.
The nurse took the correct action and should document the events that occurred in the nurses' notes (C). (A) did not occur and (B) is not indicated. The medication administration record is part of the client's medical record and should be placed in the chart, (D) when no longer current. Correct Answer: C
An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment?
The nurse who transferred the client to the chair when the fall occurred.
36.In providing care for a terminally ill resident of a long-term care facility, the nurse determines that the resident is exhibiting signs of impending death and has a "do not resuscitate" or DNR status. What intervention should the nurse implement first? A. Request hospice care for the client. B. Report the client's acuity level to the nursing supervisor. C. Notify family members of the client's condition. D. Inform the chaplain that the client's death is imminent.
The nurse's first priority is to notify the family of the resident's impending death (C). The family may request that hospice care is initiated (A). Reporting the client's acuity level (B) does not have the priority of informing the family of the client's condition. Once the family is contacted, the nurse can also contact the chaplain (D). Correct Answer: C
What is provision 2 of the code of ethics?
The nurse's primary commitment is to the patient, whether an individual, family, group, community, or population.
What is provision 7 of the code of ethics?
The nurse, in all roles and settings, advance the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.
What is provision 6 of the code of ethics?
The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.
8.The nurse formulates the nursing diagnosis of, "Ineffective health maintenance related to lack of motivation" for a client with Type 2 diabetes. Which finding supports this nursing diagnosis? A. Does not check capillary blood glucose as directed. B. Occasionally forgets to take daily prescribed medication. C. Cannot identify signs or symptoms of high and low blood glucose. D. Eats anything and does not think diet makes a difference in health.
The nursing diagnosis of ineffective health maintenance refers to an inability to identify, manage, and/or seek out help to maintain health, and is best exemplified in the client belief or understanding about diet and health maintenance (D). (A) indicates noncompliance with an action to be done in the management of diabetes. (B) represents inattentiveness. (C) reflects knowledge deficit. Correct Answer: D
What are some of the ANA standards of nursing practice?
The nursing process Ethics Education EBP/Research Quality of Practice Communication Leadership Collaboration Professional Practice Eval Resource Utilization Environmental Health Collegiality
Regardless of the various definitions of nursing, what is the central focus of *ALL* definitions?
The patient.
77.A nurse is preparing to insert a rectal suppository and observes a small amount of rectal bleeding. What action should the nurse implement? A. Administer the medication as scheduled after assessing the client's vital signs. B. Ask the pharmacist to send an alternate form of the prescribed medication to the unit. C. Withhold the administration of the suppository until contacting the healthcare provider. D. Insert the suppository very gently being careful not to further injure the rectal mucosa.
The presence of rectal bleeding is generally a contraindication for the insertion of a rectal suppository, so the nurse should withhold the medication and notify the healthcare provider (C). (A and D) may cause increased rectal bleeding. Prior to asking the pharmacist for another form of the medication, the nurse must have a new prescription from the healthcare provider (B). Correct Answer: C
When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? A. Loosen the right wrist restraint. B. Apply a pulse oximeter to the right hand. C. Compare hand color bilaterally. D. Palpate the right radial pulse.
The priority nursing action is to restore circulation by loosening the restraint (A), because blue fingers (cyanosis) indicates decreased circulation. (C and D) are also important nursing interventions, but do not have the priority of (A). Pulse oximetry (B) measures the saturation of hemoglobin with oxygen and is not indicated in situations where the cyanosis is related to mechanical compression (the restraints). Correct Answer: A
What is provision 9 of the code of ethics?
The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.
An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? A. It is important that you continue your medication while learning to meditate. B. Spiritual meditation requires a time commitment of 15 to 20 minutes daily. C. Obtain your healthcare provider's permission before starting meditation. D. Complementary therapy and western medicine can be effective for you.
The prolonged practice of meditation may lead to a reduced need for antihypertensive medications. However, the medications must be continued (A) while the physiologic response to meditation is monitored. (B) is not as important as continuing the medication. The healthcare provider should be informed, but permission is not required to meditate (C). Although it is true that this complimentary therapy might be effective (D), it is essential that the client continue with antihypertensive medications until the effect of meditation can be measured. Correct Answer: A
88.What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile? A. Maintain in a lateral position using protective wrist and vest devices. B. Position prone with a small pillow below the diaphragm. C. Raise the head and knee gatch when lying in a supine position. D. Transfer into a wheelchair close to the nurse's station for observation.
The prone position (B) using a small pillow below the diaphragm maintains alignment and provides the best pressure relief over the sacral bony prominence. Using protective (restraining) devices (A) is not indicated. Raising the head and bed gatch (C) may reduce shearing forces due to sliding down in bed, but it interferes with venous return from the legs and places pressure on the sacrum, predisposing to ulcer formation. Sitting in a wheelchair (D) places the body weight over the ischial tuberosities and predisposes to a potential pressure point. Correct Answer: B
What's the ANA's definition of nursing?
The protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.
Who defines the legal scope of practice for nursing?
The state board of a specific state.
The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this indicates the pulse is: 1 faint, barely detectable. 2 slightly weak, palpable. 3 normal. 4 bounding.
The strength of a pulse is a measurement of the force at which blood is ejected against the arterial wall. Palpation should be done using the fingertips and intensity of the pulse graded on a scale of 0 to 4 + with 0 indicating no palpable pulse, 1 + indicating a faint, but detectable pulse, 2 + suggesting a slightly more diminished pulse than normal, 3 + is a normal pulse, and 4 + indicating a bounding pulse.
While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? A. Acknowledge that she is supporting the arm correctly. B. Encourage her to keep the joint covered to maintain warmth. C. Reinforce the need to grip directly under the joint for better support. D. Instruct her to grip directly over the joint for better motion.
The wife is performing the passive ROM correctly, therefore the nurse should acknowledge this fact (A). The joint that is being exercised should be uncovered (B) while the rest of the body should remain covered for warmth and privacy. (C and D) do not provide adequate support to the joint while still allowing for joint movement. Correct Answer: A
A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? A. 9 a.m., 1 p.m., and 5 p.m. B. 8 a.m., 4 p.m., and midnight. C. Before breakfast, before lunch and before dinner. D. With breakfast, with lunch, and with dinner.
Theophylline should be administered on a regular around-the-clock schedule (B) to provide the best bronchodilating effect and reduce the potential for adverse effects. (A, C, and D) do not provide around-the-clock dosing. Food may alter absorption of the medication (D). Correct Answer: B
What are Nurse Practice Acts?
They are laws established in each state in the United States to regulate the practice of nursing.
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? A. Massage any reddened areas for at least five minutes. B. Encourage active range of motion exercises on extremities. C. Position the client laterally, prone, and dorsally in sequence. D. Gently lift the client when moving into a desired position.
To avoid shearing forces when repositioning, the client should be lifted gently across a surface (D). Reddened areas should not be massaged (A) since this may increase the damage to already traumatized skin. To control pain and muscle spasms, active range of motion (B) may be limited on the affected leg. The position described in (C) is contraindicated for a client with a fractured left hip. Correct Answer: D
A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? A. Contact the healthcare provider and complete a medication variance form. B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. C. Notify the charge nurse and complete an incident report to explain the missed dose. D. Give the missed dose at 1300 and change the schedule to administer daily at 1300.
To ensure that a therapeutic level of medication is maintained, the nurse should administer the missed dose as soon as possible, and revise the administration schedule accordingly to prevent dangerously increasing the level of the medication in the bloodstream (D). The nurse should document the reason for the late dose, but (A and C) are not warranted. (B) could result in increased blood levels of the drug. Correct Answer: D
78.The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves? A. Empty the client's urinary drainage bag. B. Draw up the irrigating solution into the syringe. C. Secure the client's catheter to the drainage tubing. D. Use aseptic technique to instill the irrigating solution.
To irrigate an indwelling urinary catheter, the nurse should first apply gloves, then draw up the irrigating solution into the syringe (B). The syringe is then attached to the catheter and the fluid instilled, using aseptic technique (D). Once the irrigating solution is instilled, the client's catheter should be secured to the drainage tubing (C). The urinary drainage bag can be emptied (A) whenever intake and output measurement is indicated, and the instilled irrigating fluid can be subtracted from the output at that time. Correct Answer: B
44.A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with a malodorous green drainage. Which dressing is best for the nurse to use first? A. Hydrogel. B. Exudate absorber. C. Wet to moist dressing. D. Transparent adhesive film.
To provide moisture and loosen the necrotic tissue, the eschar should be covered first with wet to moist dressings (C), which are discontinued and then a hydrogel alginate can be placed in the prepared wound bed to prevent further damage of granulating any surrounding tissue. Although a hydrogel (A) liquefies necrotic tissue of slough and rehydrates the wound bed, it does not address wicking the purulent drainage from the wound. Exudate absorbers (B) provide a moist wound surface, absorb exudate, and support debridement, but do not prepare the wound bed for proper healing. Transparent dressings (D) are used to protect against contamination and friction while maintaining a clean moist surface. Correct Answer: C
Trousseau sign
Trousseau sign of latent tetany is a medical sign observed in patients with low calcium. From 1 to 4 percent of normal patients will test positive for Trousseau's sign of latent tetany. negative - ok positive - hypocalcemia
What's an ethical dilemma? Professor Donadio's example of the PT on the vent.
Two (or more) clear moral principles apply, but support mutually inconsistent courses of actions.
Treat: Sulfonurea (Increase insulin) + biguanide (incr. isnulin sensitivity), diet & exercise
Type 2
TX: insulin, meal spacing
Type I
Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent? A. Height in inches or centimeters. B. Weight in kilograms or pounds. C. Triceps skin fold thickness. D. Upper arm circumference.
Upper arm circumference (D) is an indirect measure of muscle mass. (A and B) do not distinguish between fat (adipose) and muscularity. (C) is a measure of body fat. Correct Answer: D
A client with type 2 DM receives a prescription for sitagliptin (januvia). In patient teaching what should the nurse emphasize the importance of reporting which problem?
Upper respiratory infection
Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? A. Apply a condom catheter. B. Apply a skin protectant. C. Encourage increased fluid intake. D. Assess for bladder distention.
Urinary retention is the inability to void all urine collected in the bladder, which leads to uncomfortable bladder distention (D). (A and B) are useful actions to protect the skin of a client with urinary incontinence. (C) may worsen the bladder distention. Correct Answer: D
The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the nurse administer? A. 0.5 ml. B. 1 ml. C. 1.5 ml. D. 2 ml.
Using ratio and proportion: 8mg: 1ml :: 4mg:Xml 8X=4 X=0.5 Correct Answer: A
What are the two basic theoretical frameworks of ethics?
Utilitarian and Deontologic
The nurse asks the client's spouse, "Mrs. Smith, your husband told me that for the past week he has not been eating the meals you prepare. Do you agree?" This is an example of __________________ of assessment data.
Validation
What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A. It is more difficult to find a superficial vein in the feet and ankles. B. A decreased flow rate could result in the formation of a thrombosis. C. A cannulated extremity is more difficult to move when the leg or foot is used. D. Veins are located deep in the feet and ankles, resulting in a more painful procedure.
Venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation (B) which, if dislodged, could be life-threatening. Superficial veins are often very easy (A) to find in the feet and legs. Handling a leg or foot with an IV (C) is probably not any more difficult than handling an arm or hand. Even if the nurse did believe moving a cannulated leg was more difficult, this is not the most important reason for using the upper extremities. Pain (D) is not a consideration. Correct Answer: B
19.The nurse is discussing dietary preferences with a client who adheres to a vegan diet. Which dietary supplement should the nurse encourage the client to include the dietary plan? A. Fiber. B. Folate. C. Ascorbic acid. D. Vitamin B12.
Vitamin B12 is normally found in liver, kidney, meat, fish and dairy products. A vegan who consumes only vegetables without careful dietary planning and supplementation may develop peripheral neuropathy due to a deficiency in vitamin B12 (D). (A, B, and C) are commonly adequate in vegtables and fruits. Correct Answer: D
A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment? A. What is your daily calorie consumption? B. What vitamin and mineral supplements do you take? C. Do you feel that you are overweight? D. Will a clear liquid diet be okay after surgery?
Vitamin and mineral supplements (B) may impact medications used during the operative period. (A and C) are appropriate questions for long-term dietary counseling. The nature of the surgery and anesthesia will determine the need for a clear liquid diet (D), rather than the client's preference. Correct Answer: B
85.What action should the nurse implement when adding sterile liquids to a sterile field? A. Use an outdated sterile liquid if the bottle is sealed and has not been opened. B. Consider the sterile field contaminated if it becomes wet during the procedure. C. Remove the container cap and lay it with the inside facing down on the sterile field. D. Hold the container high and pour the solution into a receptacle at the back of the sterile field.
Wet or damp areas on a sterile field allow organisms to wick from the table surface and permeate into the sterile area, so the field is considered contaminated if it becomes wet (B). Outdated liquids may be contaminated and should be discarded, not used (A). The container's cap should be removed, placed facing up, and off the sterile field, not (C). To prevent contamination of the sterile field, liquids should be held close (6 inches) to the receptacle when pouring to prevent splashing, and the receptacle should be placed near the front edge to avoid reaching over or across the sterile field (D). Correct Answer: B
A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment?
What vitamin and mineral supplements do you take?
82.While the nurse is administering a bolus feeding to a client via nasogastric tube, the client begins to vomit. What action should the nurse implement first? A. Discontinue the administration of the bolus feeding. B. Auscultate the client's breath sounds bilaterally. C. Elevate the head of the bed to a high Fowler's position. D. Administer a PRN dose of a prescribed antiemetic.
When a client receiving a tube feeding begins to vomit, the nurse should first stop the feeding (A) to prevent further vomiting. (C) should then be implemented to reduce the risk of aspiration. After that, (B and D) can be implemented as indicated. Correct Answer: A
66.A 75-year-old client who has a history of end stage renal failure and advanced lung cancer, recently had a stroke. Two days ago the healthcare provider discontinued the client's dialysis treatments, stating that death is inevitable, but the client is disoriented and will not sign a DNR directive. What is the priority nursing intervention? A. Review the client's most recent laboratory reports. B. Refer the client and family members for hospice care. C. Notify the hospital ethics committee of the client situation. D. Determine who is legally empowered to make decisions.
When death is impending, it is essential for the nurse to determine who is legally empowered to make decisions regarding the use of life-saving measures for the client (D). (A) will be abnormal and will worsen without dialysis, so are not of immediate concern. (B) may help improve the client's quality of life prior to death, but is of less immediacy than determining whether actions should be taken to save a client's life. If the nurse remains unable to determine who is empowered to make decisions in this situation, the nurse may choose to contact the ethics committee (C) for a resolution. Correct Answer: D
60.A male client with venous incompetence stands up and his blood pressure subsequently drops. Which finding should the nurse identify as a compensatory response? A. Bradycardia. B. Increase in pulse rate. C. Peripheral vasodilation. D. Increase in cardiac output.
When postural hypotension occurs, the body attempts to restore arterial pressure by stimulating the baro-receptors to increase the heart rate (B), not decrease it (A). Peripheral vasoconstriction, not dilation (C), of the veins and arterioles occurs with venous incompetence through the baro-receptor reflex. A decrease in cardiac output, not an increase (D), occurs when orthostatic hypotension occurs. Correct Answer: B
What is moral distress?
When the nurse knows the right thing to do but either personal or institutional factors make it difficult to do the right thing.
0.24 seconds Explanation: In adults, the normal range for the PR is 0.12 to 0.20 seconds. A PR internal of 0.24 seconds would indicate a first-degree heart block.
Which PR interval presents a first-degree heart block?
Immediate bystander CPR Explanation: The treatment of choice for v-fib is immediate bystander cardiopulmonary resuscitation (CPR), defibrillation as soon as possible, and activation of emergency services
Which of the following is the treatment of choice for ventricular fibrillation
75.A male client arrives at the outpatient surgery center for a scheduled needle aspiration of the knee. He tells the nurse that he has already given verbal consent for the procedure to the healthcare provider. What action should the nurse implement? A. Witness the client's signature on the consent form. B. Verify the client's consent with the healthcare provider. C. Notify the healthcare provider that the client is ready for the procedure. D. Document that the client has given consent for the needle aspiration.
Written informed consent is required prior to any invasive procedure. The healthcare provider must explain the procedure to the client, but the nurse can witness the client's signature on a consent form (A). (B) is not necessary since written consent must be obtained. (C) is not correct because written consent has not been obtained. (D) must occur after written consent is obtained. Correct Answer: A
Can an RN's license be suspended/revoked?
Yes! If said RN becomes carless, reckless, and negligent of ones career and patients.
Expected Outcome
a measurable criterion to evaluate goal achievement
principles of surgical asepsis
a sterile object remains sterile only when touched by another sterile object only sterile objects may be placed on a sterile field a sterile object or field out of range of vision or below the waist is contaminated a sterile object becomes contaminated by prolonged exposure to air when a sterile object comes in contact w/ a wet surface, the sterile field is broken fluid flows in the direction of gravity the edges of the sterile field are considered contaminated
A nurse is teaching a client how to administer medication through a jejunostomy tube. Which of the following instructions should the nurse include? a. "Flush the tube before and after each medication." b. "Mix your medications with your enteral feeding." c. "Push tablets throught the tube slowly." d. "Mix all the crushed medications prior to dissolving them in water."
a. "Flush the tube before and after each medication."
A nurse in an outpatient clinic is caring for a client who has a new prescription for an antihypertensive medication. Which of the following instructions should the nurse give the client? a. "Get up and change positions slowly." b. "Avoid eating aged cheese and smoked meat." c. "Report any unusual bruising or bleeding to the doctor immediately." d. "Eat the same amount of foods that contain vitamin K every day."
a. "Get up and change positions slowly."
A nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired nurse should the nurse identify as appropriate for the planning step of the nursing process? a. "I will determine the most important client problems that we should address." b. "I will review the past medical history on the client's record to get more information." c. "I will go carry out the new prescriptions from the provider." d. "I will ask the client if his nausea has resolved."
a. "I will determine the most important client problems that we should address."
A nurse is cautioning the mother of an 8-month-old infant about safety. Which of the following statements by the mother indicates an understanding of safety for the infant? a. "My baby loved to play with his crib gym, but I took it away from him." b. "I just bought a soft mattress so my baby will sleep better." c. "My baby really likes sleeping on the fluffy pillow we just got for him." d. "I put the baby's car seat out of the way on the table after I put him in it."
a. "My baby loved to play with his crib gym, but I took it away from him."
A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following responses should the nurse make? a. "Water helps clear the tube so it doesn't get clogged." b. "Flushing helps make sure the tube stays in place." c. "This will help you get enough fluids." d. "Adding water makes the formula less concentrated."
a. "Water helps clear the tube so it doesn't get clogged."
A nurse is talking with parents of a 12-year-old child. Which of the following issues verbalized by the patient should the nurse identify as the priority? a. "We just don't understand why our son can't keep up with the other kids in simple activities like running and jumping." b. "Our son keeps trying to find ways around our household rules. He always wants to make deals with us." c. "We think our son is trying too hard to excel in math just to get the top grades in his class." d. "Our son is always afraid the kids in school will laugh at him because he likes to sing."
a. "We just don't understand why our son can't keep up with the other kids in simple activities like running and jumping."
A nurse is caring for a client who asks what her Snellen eye test results mean. The client's visual acuity is 20/30. Which of the following responses should the nurse make? a. "Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet." b. "Your right eye can see the chart clearly at 20 feet, and your left eye can see the chart clearly at 30 feet." c. "Your eyes see at 30 feet what visually unimpaired eyes see at 20 feet." d. "Your left eye can see the chart clearly at 20 feet, and your right eye can see the chart clearly at 30 feet."
a. "Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet."
The nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia? a. A client who has nasogastric suctioning b. A client who has chronic constipation c. A client who has syndrome of inappropriate antidiuretic hormone d. A client who took an overdose of sodium bicarbonate antacids
a. A client who has nasogastric suctioning
A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing? a. Assault b. Battery c. False imprisonment d. Invasion of privacy
a. Assault
A newly licensed nurse is reporting to the charge nurse about the care she gave to a client. She states "The client said his leg pain was back, so I checked his medical record, and he last received his pain medication 6 hours ago. The prescription reads every 4 hours PRN for pain, so I decided he needs it. I checked with the unit nurse to observe me preparing and administering it. I checked with the client 40 minutes later, and he said his pain is going away." The charge nurse should inform the newly licensed nurse that she left out which of the following steps of the nursing process? a. Assessment b. Planning c. Intervention d. Evaluation
a. Assessment
A nurse is caring for a client who is 24 hr postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for "real food." The nurse tells the client that she will call the surgeon and ask. The surgeon hears the nurse's report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking?" a. Basic b. Commitment c. Complex d. Integrity
a. Basic
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.The nurse should suspect the tea includes which of the following ingredients? a. Chamomile b. Ginseng c. Ginger d. Echinacea
a. Chamomile
A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy? a. Collaborating with providers to perform obesity screenings during routine office visits b. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity c. Providing specialized intraoperative training regarding surgical treatments for obesity d. Educating acute care nurses on postoperative complications related to obesity
a. Collaborating with providers to perform obesity screenings during routine office visits
A nurse is reviewing the medical record of a client who has hypocalcemia. The nurse should identify which of the following findings as risk factors for the development of this electrolyte imbalance? a. Crohn's disease b. Postoperative following appendectomy c. History of bone cancer d. Hyperthyroidism
a. Crohn's disease
A nurse is caring for a client who has a prescription for a 24-hr urine collection. Which of the following actions should the nurse take? a. Discard the first voiding b. Keep the urine in a single container at room temperature c. Ask the client to urinate and pour the urine into a specimen container d.Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container
a. Discard the first voiding
A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement?? a. Encourage the client to perform antiembolic exercises every 2 hr b. Instruct the client to cough and deep breathe every 4 hr c. Restrict the client's fluid intake d. Reposition the client every 4 hr
a. Encourage the client to perform antiembolic exercises every 2 hr
A nurse is beginning a complete bed bath for a client. After removing the client's gown and placing a bath blanked over him, which of the following areas should the nurse wash first? a. Face b. Feet. c. Chest d. Arms
a. Face
A nurse is preparing to admit a client who is suspected to have pulmonary tuberculosis. Which of the following actions should the nurse plan to perform first? a. Implement airborne precautions b. Obtain a sputum culture c. Administer prescribed antituberculosis medications d. Recommend a screening test for family members
a. Implement airborne precautions
A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse anticipate including 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. Infuse hypotonic IV fluids
A nurse is caring for a client who has a new prescription for antihypertensive medication. Prior to administering the medication, the nurse uses an electronic database to gather information about the medication and the effects it might have on the client. Which of the following components of critical thinking is the nurse using when he reviews the medication information? a. Knowledge b. Experience c. Intuition d. Competence
a. Knowledge
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 he is 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 and to think of something else
a. Offer information on a relaxation technique and ask the client if he is interested in trying it
A nurse prepares an injection of morphine to administer to a client who reports pain. Prior to administering the medication, the nurse assists another client onto a bedpan. She asks a second nurse to give the injection. Which of the following actions should the second nurse take? a. Offer to assist the client who needs the bedpan b. Administer the injection the other nurse prepared c. Prepare another syringe and administer the injection d. Tell the client who needs the bedpan she will have to wait for her nurse
a. Offer to assist the client who needs the bedpan
A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse? a. Orient the client to his room b. Conduct a client care conference c. Review medical prescription d. Develop a plan of care
a. Orient the client to his room
A nurse at a clinic is collecting data about pain from a client who reports severe abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. Which of the following pain characteristics is the nurse attempting to determine? a. Presence of associated manifestations b. Location of the pain c. Pain quality d. Aggravating and relieving factors
a. Presence of associated manifestations
A nurse is planning care for a client who develops dyspnea and feels tired after completing her 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 to bathe the client
a. Schedule rest periods during morning care
A nurse in a health clinic is caring for a 21-year-old client who reports a sore throat. The client tells the nurse that he has not seen a doctor since high school. Which of the following health screenings should the nurse expect the provider to perform for this client? a. Testicular examination b. Blood glucose c. Fecal occult blood d. Prostate-specific antigen
a. Testicular examination
A mother tells the nurse that her 2-year-old toddler has temper tantrums and says "no" every time the mother tries to help her get dressed. The nurse should recognize the toddler is manifesting which of the following stages of development? a. Trying to increase her independence b. Developing a sense of trust c. Establishing a new identity d. Attempting to master a skill
a. Trying to increase her independence
In developing a nursing care plan which has the greatest priority: a. aspiration b. skin breakdown c. altered nutrition d. self-care deficit
a. aspiration aspiration, or the entry of a FO such as food or fluids into the lungs, may cause hypoxia or respiratory distress. Therefore, this is the highest priority in establishing the client's plan of care
Identify the two steps of a nursing assessment: a. b.
a. collection of information from primary and secondary sources b. interpretation and validation of data
Define: a. cue: b. inference:
a. cue: information that you obtain through senses b. inference: your judgment or interpretation of these cues
Explain: a. diagnostic reasoning b. inference
a. diagnostic reasoning: analytical process for determining a patient's health problems and selecting proper therapies b. inference: the process of drawing conclusions from related pieces of evidence and previous experience with the evidence
Nurses establish priorities in relation to importance and time. Explain: a. high priority b. intermediate priority c. low priority
a. high priority: if untreated, result in harm to the patient or others b. intermediate priority: involve nonemergent, nonthreatening needs of the patient c. low priority: are not always directly related to specific illness or prognosis
State the guidelines to use to reduce errors when formulating the diagnostic statement:
a. identify the patient's response, not the medical diagnosis b. identify a North American Nursing Diagnosis Association NANDA diagnostic statement rather than the symptom c. identify a treatable etiology or risk factor rather than a clinical sign or chronic problem d. identify the problem caused but the treatment or diagnostic study rather than the treatment or study itself e. identify the patient's response to the equipment rather than the equipment itself f. identify the patient's problems rather than your problems with nursing care g. identify the patient's problem rather than the nursing intervention h. identify the patient's problem rather than the goal of care i. make professional rather than prejudicial judgments j. avoid legally inadvisable statements k. identify the problem and etiology to avoid a circular statement l. identify only one patient problem in the diagnosis statement
Discuss the standards for critical thinking: a. intellectual standards b. professional standards
a. intellectual standards: clear, precise, specific, accurate, relevant, plausible, consistent, logical, deep, broad, complete, significant, adequate, fair b. professional standards: ethical criteria, for evaluation, professional responsibility
Identify ways the nurse can manage stress (a-e)
a. learn to recognize when you are feeling stressed b. take a time out c. discuss the difficult and stressful patient care experiences you are having d. participate in opportunities to make decisions e. attend a stress management class
Identify some factors within the health care environment that affect the ability to set priorities (a-g)
a. model for delivering care b. nursing unit's workflow routine c. staffing levels d. interruptions from other care providers e. available resources f. policies and procedures g. supply access
During an interview, the following are used: a. observation b. open-ended questions c. leading questions d. back channeling e. probing f. direct closed-ended questions
a. observation: nonverbal communication b. open-ended questions: prompts patients to describe a situation in more than 2 words c. leading questions: risky, limits information d. back channeling: active listening prompts e. probing: encourages a full description without trying to control the direction of the story f. direct closed-ended questions: limit the patients answers to 1/2 words
Identify the concepts and behaviors of a critical thinker (a-g)
a. seek the true meaning of a situation b. be tolerant of different views and one's own prejudices c. anticipate possible results or consequences d. be organized e. trust in your own reasoning processes f. be eager to acquire new knowledge and value learning g. reflect on your own judgments
List the tips suggested to foster knowing your patient (a-e)
a. spend more time during initial patient assessment to observe behavior and measure physical findings b. listen to their accounts of their experiences with illness c. consistently check on patients to assess and monitor problems d. ask to have the patient assigned to you over consecutive days e. social conversation and continuity
Lis the tips on how to use reflection (a-f)
a. stop and think about what is going on with your patient b. reflect carefully on critical incidents c. think about your feelings and the painful experiences you sometimes have d. take time to reflect at the end of the day e. keep all written care plans or clinical notes for future resources f. keep a personal journal
2 primary types of data: a. subjetive b. objective
a. subjective: includes the patient's verbal descriptions of their health problems b. objective: data through measurements / observations of a patient's health status
While the nurse is administering flu immunizations in November to a group of older adults at a community senior citizens' center, one of the seniors expresses a fear of contracting the flu from the injection. The nurse reassures the senior that this is not possible because the vaccine contains a dead virus and explains that this injection will produce _________ immunity, in which the senior's body will make antibodies to the virus.
active
Pre bed bath assessment say to cna
activity level of the patient
Collaborative problem
actual or potential physiological complication that is monitored in collaboration with others
Client is in clinic w/ acute gastritis. Which nursing diagnosis is highest priority?
acute pain R/T inflammation
which client instruction is important to prevent complications due to reduced body flora
add buttermilk or active culture yogurt to the diet daily
when do you assess vital signs
admission to any health care agency policy and procedures any time there is a change in the patient's health status or condition before and after surgical, diagnostic, or invasive procedures or interventions before and after activity that may increase risk before administering meds that effect cardiovascular or respiratory functioning
instilling ear solutions adult; child
adult: pull pinna up and back child: pull pinna down and back
nursing diagnosis "high risk for infection" is most relevant for a client with which hematologic problem?
agranulocystosis
caring for a patient who is 3 hours postoperative laryngectomy the nurse's highest priority is
airway patency
order for inhalers-asthma attack
albuterol
native american
allow patient's family to stay in the room
docusate sodium is a stool softener, desired effect is to soften hard stool for ease of elimination
alter consistency of stool
stroke volume
amount in ml of blood ejected with each contraction of the left ventricle
Nursing sensitive patient outcome
an individual, family, or community state, behavior,, or perception that is measurable in response to a nursing intervention
dehiscence
an unintentional opening in a surgical wound prior to healing
Data interpretation:
analyzing clusters of defining characteristics of risk factors
Collaborative intervetions
are interdependent nursing interventions that require the combined knowledge, skill, and expertise of multiple care professionals
Independent nursing interventions
are nurse initiated interventions that do not require direction or an order from another HCP
patient diagnosed with non-small cell carcinoma of the lung question patient of these related history factors
asbestos exposure cigarette smoking exposure to uranium
75 year old 2 days post op from hip replacement surgery asks for a bedpan. How should the nurse position?
ask her to roll to the un-operated side, slide bed pan under her, and then roll back onto pan
prior to applying sensor
ask if patient has a latex allergy
score of 16 on braden scale
at risk
what temperature is at risk for hypothermia
at special risk for hypothermia core temperature drops below 95F / 35 c
used to treat symptomatic bradycardia
atropine
what action should the nurse take to assess for atelectasis
auscultate the client's breath sounds; atelectasis is a condition in which the alveoli collapse. Dull or absent breath sounds along with changes in breathing patterns, are expected findings
neonatal safety concerns
avoid behaviors that might harm fetus, never leave the infant unattended, use crib rails, monitor setting for objects that are choking hazards, use car seats properly
Coumadin-diet recommendations
avoid ingesting foods high in vitamin K because this reduces the drug's effect
A nurse at a provider's office is talking about routine screenings with a 45-year-old female client who has no specific family history of cancer or diabetes mellitus. Which of the following client statements indicates that the client understands how to proceed? a. "So, I don't need the colon cancer procedure for another 2 or 3 years." b. "For now, I should continue to have a mammogram each year." c. "Because the doctor just did a pap smear, I'll come back next year for another one." d. "I had my blood glucose test last year, so I won't need it again till next year."
b. "For now, I should continue to have a mammogram each year."
A nurse is instructing a client who has a new diagnosis of narcolepsy about measures that might help with self-management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. "I'll add plenty of carbohydrates to my meals." b. "I'll take a short nap whenever I feel little sleepy." c. "I'll make sure I stay warm when I am at my desk at work." d. "It's okay to drink alcohol as long as I limit it to one drink per day."
b. "I'll take a short nap whenever I feel little sleepy."
A nurse in an ambulatory care clinic is caring for a client who had a mastectomy 6 months ago. The client tells the nurse that she has not had much desire for sexual relations since her surgery, stating, "My body is so different now." Which of the following should the nurse make? a. "Really, you look just fine to me.: There's no need to feel undesirable." b. "I'm interested in finding out more about how your body feels to you." c. "Consider an afternoon at a spa. A facial will make you feel more attractive." d. "It's still too soon to expect to feel normal. Give it a little more time."
b. "I'm interested in finding out more about how your body feels to you."
A nurse is teaching a young adult client about health promotion and illness prevention. Which of the following statements by the client indicates an understanding of the teaching? a. "I already had my immunizations as a child, so I'm protected in that area." b. "It is important to schedule routine health care visits even if I am feeling will." c. "I will just go to an urgent care center for my routine medical care." d. "There's no reason to seek help if I am feeling stressed because it's just part of life."
b. "It is important to schedule routine health care visits even if I am feeling will."
A nurse is caring for a client who is recovering from a myocardial infarction and a cardiac catheterization. The client states, "I am concerned that things might be a little, you know, 'different' with my wife when I get home." Which of the following statements should the nurse make? a. "Sounds like something you should discuss with her when you get home." b. "It sounds like you are concerned about sexual functioning. Let's discuss your concerns." c. "Oh, I wouldn't be too concerned. Things will be fine as soon as we get you home." d. "Just make sure you take your medication as directed, and you should be fine."
b. "It sounds like you are concerned about sexual functioning. Let's discuss your concerns."
A nurse is counseling a middle adult client who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further? a. "I am struggling to accept that my parents are aging and need so much help." b. "It's been so stressful for me to think about having intimate relationships c. "I know I should volunteer my time for a good cause but maybe I'm just selfish." d. "I love my grandchildren but my son expects me to relive my parenting days."
b. "It's been so stressful for me to think about having intimate relationships
A nurse is evaluating teaching on a client who has a new prescription for a sequential compression device. Which of the following client statements should indicate to the nurse the client understands the teaching? a. "This device will keep me from getting sores on my skin." b. "This thing will keep the blood pumping through my leg." c. "With this thing on, my leg muscles won't get weak." d. "This device is going to keep my joints in good shape."
b. "This thing will keep the blood pumping through my leg."
A nurse is caring for a client whose partner passed away 4 months ago and who has been recently diagnosed with diabetes mellitus. He is tearful and states, "How could you possibly understand what I am going through?" Which of the following should the nurse make? a. "It takes time to get over the loss of a loved one." b. "You are right. I cannot really understand. Perhaps you'd like to tell me more about what you're feeling." c. "Why don't you try something to take your mind off your troubles, like watching a funny movie." d. "I might not share your exact situation, but i do know what people go through when they deal with a loss."
b. "You are right. I cannot really understand. Perhaps you'd like to tell me more about what you're feeling."
A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients should the nurse anticipate 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 alkalosis d. A client who has abdominal ascites
b. A client who has heart failure
A nurse in a provider's office is collecting data from the mother of a 12-month-old infant. The client states that her son is old enough for toilet training. Following an educational session with the nurse, the client now states that she will postpone toilet training until her son is older. Learning has occurred in which of the following domains? a. Cognitive b. Affective c. Psychomotor d. Kinesthetic
b. Affective
A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/90 mm Hg. The client denies any history of hypertension. Which of the following actions should the nurse take first? a. Request a prescription for an anihypertensive medication b. Ask the client if she is having pain c. Request a prescription for an antianxiety medication d. Return in 30 minutes to recheck the client's blood pressure
b. Ask the client if she is having pain
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 the nurse should take before attempting this particular mind-body intervention? a. Tell the client the goal of the 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. Ask whether the client is comfortable with using prayer
A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this client's choice is an example of which of the following ethical principles? a. Fidelity b. Autonomy c. Justice d. Nonmaleficence
b. Autonomy
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 then 30 mL/hr d. Encourage independent ambulation four times a day
b. Check the client's weight each morning
A nurse is working with a newly licensed nurse who is administering medications to clients. Which of the following actions should the nurse identify as an indication that the newly hired nurse understands medication error prevention? a. Taking all medications out of the unit-dose wrappers before entering the client's room b. Checking with the provider when a single dose requires administration of multiple tablets c. Administering a medication, then looking up the usual dosage range d. Relying on another nurse to clarify a medication prescription
b. Checking with the provider when a single dose requires administration of multiple tablets
A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards? a. Monitoring evidence-based practice for clients who have a specific diagnosis b. Ensuring that health care providers comply with regulations c. Setting quality standards for accreditation of health care facilities d. Determining if medications are safe for administration to clients
b. Ensuring that health care providers comply with regulations
A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend? a. Macaroni and cheese b. Fresh fruit and whole what toast c. Bread pudding and yogurt d. Roast chicken and white rice
b. Fresh fruit and whole what toast
A nurse is reviewing a client's medications. They include cimetidine and imipramine. Knowing that cimetidine decreases the metabolism of imipramine, the nurse should identify that this combination is likely to result in which of the following effects? a. Decreased therapeutic effects of cimetidine b. Increased risk of imipramine toxicity c. Decreased risk of adverse effects of cimetidien d. Increased therapeutic effects of imipramine
b. Increased risk of imipramine toxicity
A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take? a. Give the client thin liquids b. Instruct the client to tuck her chin when swallowing c. Have the client us a straw d. Encourage the client to lie down and rest after meals
b. Instruct the client to tuck her chin when swallowing
A nurse is talking with a client who recently attended a cholesterol screening event and a heart-healthy nutrition presentation at a neighborhood center. The client's total cholesterol was 248 mg/dL. After seeing the provider, the client started taking medication to lower his cholesterol level. The client was later hospitalized for severe chest pain, and subsequently enrolled in a cardiac rehabilitation program. Which of the following activities for the client is an example of primary prevention? a. Cholesterol screening b. Nutrition presentation c. Medication therapy d. Cardiac rehabilitation
b. Nutrition presentation
A nurse is reviewing car seat safety with the parents of a 1-month-old infant. When reviewing car seat use, which of the following instructions should the nurse include? a. Use a car seat that has a three-point harness system b. Position the car seat so that the infant is rear-facing c. Secure the car seat in the front passenger seat of the vehicle d. Convert to a booster seat after 12 months
b. Position the car seat so that the infant is rear-facing
A nurse manager of a medical-surgical unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which of the following staff members should the nurse assign this client? a. Charge nurse b. RN c. Practical Nurse (PN) d. Assistive personnel (AP)
b. RN
A nurse is caring for a client who states. "I have to check with my wife and see if she thinks I am ready to go home." The nurse replies, "How do you feel about going home today?" Which clarifying technique is the nurse using to enhance communication with the client? a. Pacing b. Reflecting c. Paraphrasing d. Restating
b. Reflecting
A nurse is preparing to inject heparin subcutaneously for a client who is postoperative. Which of the following actions should the nurse take? a. Use a 22-gauge needle b. Select a site on the client's abdomen c. Spread the skin with the thumb and index finger d. Observe for bleb formation to confirm proper placement
b. Select a site on the client's abdomen
A nurse is caring for a school-age child who is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take? a. Touch the child's arm b. Sit at eye level with the child c. Stand facing the child d. Stand with a relaxed posture
b. Sit at eye level with the child
A nurse is observing a client drawing up and mixing insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place? a. The client is able to discuss the appropriate technique b. The client is able to demonstrate the appropriate technique c. The client states that he understands d. The client is able to write the steps on a piece of pater
b. The client is able to demonstrate the appropriate technique
3 infectious agents
bacteria, viruses, fungi
physical assessment finding in a patient with a lower respiratory problem best supports diagnosis of ineffective airway clearance
basilar crackles
Risk Taking
be willing to recommend alternative approaches to nursing care
At what step in the procedure should the nurse don sterile gloves
before cleansing the client's hip incision
total serum cholesterol
below 200
Beneficence =
benefit the patient
Rinne test, negative
bone conduction of sound is greater than air conduction of sound
A nurse is talking with the parents of a 10-year-old child who is concerned that their son is becoming secretive, such as closing the door when he showers, and dresses. Which of the following responses should the nurse make? a. "Perhaps you should try to find out what he is doing behind those closed doors." b. "Suggest that he leave the door ajar for his own safety." c. "At this age, children tend to become modest and value their privacy." d. "You should establish a disciplinary plan to stop this behavior."
c. "At this age, children tend to become modest and value their privacy."
A nurse is providing preoperative education for a client who will undergo a mastectomy the next day. Which of the following statements should the nurse identify as an indication that the client is ready to learn? a. "I don't want my spouse to see my incision." b. "Will you give me pain medicine after the surgery?" c. "Can you tell me about how long the surgery will take?" d. "My roommate listens to everything I say."
c. "Can you tell me about how long the surgery will take?"
A nurse is talking with an adolescent who is having difficulty dealing with several issues. Which of the following issues should the nurse identify as the priority? a. "I kind of like this boy in my class, but he doesn't like me back." b. "I want to hang out with the kids in the science club, but the jocks pick on them." c. "I am so fat, I skip meals to try to lose weight." d. "My dad wants me to be a lawyer like him, but I just want to dance."
c. "I am so fat, I skip meals to try to lose weight."
A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further? a. "I have my own apartment now, but it's not easy living away from my parents." b. "It's been so stressful for me to even think about having my own family." c. "I don't even know who I am yet, and now I'm supposed to know what to do." d. "My girlfriend is pregnant, and I don't think I have what it takes to be a good father."
c. "I don't even know who I am yet, and now I'm supposed to know what to do."
A nurse in a surgeon's office is proving preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse that he will prepare his advance directives before he goes to the hospital. Which of the following statements made by the client should indicate to the nurse an understanding of advance directives? a. "I'd rather have my brother make decisions for me, but I know it has to be my wife." b. "I know they won't go ahead with the surgery unless I prepare these forms." c. "I plan to write that I don't want them to keep me on a breathing machine." d. "I will get my regular doctor to approve my plan before I hand it in at the hospital."
c. "I plan to write that I don't want them to keep me on a breathing machine."
A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the devices? a. "I'll wait to use the device until it's absolutely necessary." b. "I'll be careful about pushing the button too much so I don't get an overdose." c. "I should tell the nurse if the pain doesn't stop while I am using this device." d. "I will ask my adult child to push the dose button when I am sleeping."
c. "I should tell the nurse if the pain doesn't stop while I am using this device."
A charge nurse is teaching about the care of a client who has methiccillin-resistant Stphyloccocus aures (MRSA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. "I should obtain a specimen for culture and sensitivity after the first dose of an antimicrobial." b. "MRSA is usually resitant to vancomycin, so another antimicrobial will be prescribed." c. "I will need to monitor the client's serum antimicrobial levels during the course of therapy." d. "To decrease resistance, antimicrobial therapy is discontinued when the client is no longer febrile."
c. "I will need to monitor the client's serum antimicrobial levels during the course of therapy."
A nurse is reviewing nutritional guidelines with the parents of a 2-year-old toddler. Which of the following parent statements should indicate to the nurse an understanding of the teaching? a. "I should keep feeding my son whole milk until he is 3 years old." b. "It's okay for me to give my son a cup of apple juice with each meal." c. "I'll give my son about 2 tablespoons of each food at mealtimes." d. "My son loves popcorn and I know it is better for him than sweets."
c. "I'll give my son about 2 tablespoons of each food at mealtimes."
A nurse is instructing a group of nursing students about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the students 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 her spouse on her durable power of attorney form
c. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill
A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client's vital signs and notes an elevation in blood pressure and heart rate. The nurse should recognize this response as which part of the general adaptation syndrom (GAS)? a. Exhaustion stage b. Resistance stage c. Alarm stage d. Recovery reaction
c. Alarm stage
A nurse is caring for an older adult client who has been following the facility's routine and bathing in the morning. However, at home, she always takes a warm bath just before bedtime. Now she is having difficulty sleeping at night. Which of the following actions should the nurse take first? a. Rub the client's back for 15 min before bedtime b. Offer the client warm milk and crackers at 2100 c. Allow the client to take a bath in the evening d. Ask the provider for a sleeping medication
c. Allow the client to take a bath in the evening
A nurse is caring for a client who has stage IV lung cancer and is 3 days postoperative 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 daughter's wedding." Based on Kubler-Ross' model, which stage of grief is the client experiencing? a. Anger b. Denial c. Bargaining d. Acceptance
c. Bargaining
A nurse is preparing information for change-of-shift report. Which of the following information should the nurse include in the report? a. Input and output for the shift b. Blood pressure from the previous day c. Bone scan scheduled for today d. Medication routine from the medication administration record
c. Bone scan scheduled for today
An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? a. Irrigate the affected area with running water b. Wash the affected area with antibacterial soap c. Brush the chemical off the skin and clothing d. Leave the clothing in place until emergency personnel arrive
c. Brush the chemical off the skin and clothing
A nurse is caring or a 20-year-old client who is sexually active and has come to the college health clinic for a first-time checkup. Which of the following interventions should the nurse perform first to determine the client's need for health promotion and disease prevention? a. Measure vital signs b. Encourage HIV srceening c. Determine risk factors d. Instruct the client to use condoms
c. Determine risk factors
A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the charge nurse include as a developmental task for a young adult? a. Becoming actively involved in providing guidance to the next generation b. Adjusting to major changes in roles and relationships due to losses c. Devoting a great deal of time to establishing an occupation d. Finding oneself "sandwiched" between and being responsible for two generations
c. Devoting a great deal of time to establishing an occupation
A nurse in a family practice clinic is performing a physical examination of an adult client. Which part of her hands should she use during palpation for optimal assessment of skin temperature? a. Palmar surface b. Fingertips c. Dorsal surface d. Base of the fingertips
c. Dorsal surface
A nurse is teaching the father of a 12-year-old boy about manifestations of puberty. The nurse should explain that which of the following physical changes occurs first? a. Appearance of downy hair on the upper lip b. Hair growth in the axillae c. Enlargement of the testes and scrotum d. Deepening of the voice
c. Enlargement of the testes and scrotum
During an abdominal examination a nurse in a provider's office determines that a client has abdominal distension. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distension should the nurse suspect? a. Fat b. Fluid c. Flatus d. Hernias
c. Flatus
A nurse is talking with the parent of a 4-year-old child who states that his child is waking up at night with nightmares. Which of the following interventions should the nurse suggest? a. Offer the child a large snack before bedtime b. Allow the child to watch an extra 30 min of TV in the evening c. Have the child take an afternoon nap d. Increase physical activity before bedtime
c. Have the child take an afternoon nap
A nurse in an outpatient surgical center is admitting a client for a laparoscopic procedure. The client has a prescription for preoperative diazepam. Prior to administering the medication, which of the following actions is the nurse's priority? a. Teaching the client about the purpose of the medication b. Giving the medication at the administration time the provider prescribed c. Identifying the client's medication allergies d. Documenting the client's anxiety level
c. Identifying the client's medication allergies
A nurse is instructing a group of nursing students about the responsibilities of organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students 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. Nonmaleficence
c. Justice
A nurse is caring for a client who is 1 day postoperative following a total knee arthroplasty. The client states his pain level is 10 on a sclae of 0 to 10. After reviewing the client's medication administration record, which of the following medications should the nurse administer? a. Meperidine 75 mg IM b. Fentanyl 50 mcg/hr c. Morphine 2 mg IV d. Oxycodone 10 mg PO
c. Morphine 2 mg IV
A nurse observes smoke coming from under the door of the staff's lounge. Which of the follow actions is the nurse's priority? a. Extinguish the fire b. Activate the fire alarm c. Move clients who are nearby d. Close all the doors on the unit
c. Move clients who are nearby
When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? a. Keep the sterile field at least 6 ft away form the client's bedside b. Instruct the client to refrain from coughing and sneezing during the dressing change c. Place a mask on the client to limit the spread of micro-organisms into the surgical wound d. Keep a box of facial tissues nearby for the client to use during the dressing change
c. Place a mask on the client to limit the spread of micro-organisms into the surgical wound
A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client? a. Decreased subcutaneous fat b. Muscle atrophy c. Pressure ulcer d. Fecal impaction
c. Pressure ulcer
A nurse is caring for a client who had an amphetamine overdose and has sensory overload. Which of the following interventions should the nurse implement? a. Immediately complete a thorough assessment b. Put the client in a room with a client who has a hearing loss c. Provide a private room, and limit stimulation d. Speak at a higher volume to the client, and encourage ambulation
c. Provide a private room, and limit stimulation
A nurse on a medical-surgical unit has received change-of-shift report and will care for four clients. Which of the following should the nurse assign to an assistive personnel (AP)? a. Feeding a client who was admitted 24 hr ago with aspiration pneumonia b. Reinforcing teaching with a client who is learning to walk using a quad cane c. Reapplying a condom catheter for a client who has urinary incontinence d. Applying a sterile dressing to a pressure ulcer
c. Reapplying a condom catheter for a client who has urinary incontinence
A nurse has notice several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on a break. Which of the following actions should the nurse take? a. Alert the American Nurses Association b. Fill out an incident report c. Report the observations to the nurse manager on the unit d. Leave the nurse alone to sleep
c. Report the observations to the nurse manager on the unit
A nurse is completing discharge instructions for a client who has COPD. The nurse should identify that the client understands the orthopneic position when she states that she will do which of the following when she has difficulty breathing at night? a. Lie on her back with her head and shoulders on a pillow b. Lie flat on her stomach with her head to one side c. Sit on the side of her bed and rest her arms over pillows on top of her bedside table d. Lie on her side with her weight on her hip and shoulder with her arm flexed in front of her.
c. Sit on the side of her bed and rest her arms over pillows on top of her bedside table
A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family assisting with all 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 her muscles and promote healing b. The client needs to be given privacy at times for self-reflecting and organizing her life c. The client's sense of loss can be lessened through retaining control of certain areas of her life d. Performing ADLs is required prior to discharge from an acute care facility
c. The client's sense of loss can be lessened through retaining control of certain areas of her life
A nurse attempts to collect a capillary blood specimen via finger stick for a blood glucose monitoring from a client who has diabetes mellitus. The nurse is unable to obtain an adequate drop of blood for the reagent strip. Which of the following actions should the nurse take first? a. Puncture another finger to obtain a capillary specimen b. Test the urine with a urine reagent strip c. Wrap the hand in a warm, moist cloth d. Perform a venipuncture to obtain a venous sample
c. Wrap the hand in a warm, moist cloth
postural hypotension
can occur when the client has been lying or sitting for a prolonged period and quickly rises to erect position
most important factor determining how well a patient might tolerate anesthesia and surgery is
cardiopulmonary function
what is the physical assessment in regards to safety?
check mobility status, ability to communicate, level of awareness, sensory perception
crutch size
check the distance between the axilla and the top of the crutch, it should be at leasst 3 finger widths or 1 to 2 inches. If the crutches are not the correct length, the client should sustain axillary nerve damage
toddler safety concerns
childproof home environment, prevent poisoning, be alert to manifestations of child abuse, use car seats properly
circle the amount of drainage on the initial dressing
circling the small amount of drainage allows the nurse to compare any changes in the amount of drainage at a later time
takes NPH insulin each morning what reason to hold usual morning NPH insulin dose
client is NPO for surgical debridement of a leg ulcer at 11 am
when performing deep breathing exercises
client should inhale through the nose and exhale slowly through the mouth without pursing the lips. The nurse should demonstrate the entire procedure again for the best learning by the client
Defining characteristics:
clinical criteria that are observable and verifiable
salmeterol (Severent) for a patient with asthma
close lips tightly around the mouthpiece and breathe in deeply and quickly
sterilization
complete elimination of all microorganims and spores
Altruism =
concern for welfare and well-being of others
Related factor:
condition or etiology identified from the patient's assessment data, or actual or potential responses to the health problem
Respiratory alkalosis
confusion, tingling of extremities, and deep and rapid respirations
indicates altered nutrition
conjunctival sac is pale in appearance skin over sternum tents when pinched the lips are dry and cracked
VRSA precautions
contact AND airborne precaution (private room, door closed, negative pressure)
MRSA precautions
contact precaution ONLY
Insulin pen benefits
convenient, easy to use, travel benefits, mistake free
Crede method
crede method is used for those w/ atonic bladders - apply downward pressure at the suprapubic region
before admin of antibiotics
culture and sensitivity
what is obtained before starting any iv antibiotic
cultures
A client who has a prescription for fluid restriction asks the nurse for a mid-afternoon snack. What is the best snack to bring the client?
custard
A nurse is caring for a client who is 3 days postoperative following a below-the-knee amputation as a result of a motor vehicle crash. Which of the following client statements indicates to the nurse that the client has a distorted body image? a. "I'll be able to function exactly as I did before the accident." b. "I just can't stop crying." c. "I am so mad at that guy who hit us. I wish he lost a leg." d. "I don't even want to look at my leg. You can check the dressing."
d. "I don't even want to look at my leg. You can check the dressing."
A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority? a. "I spent my whole life dreaming about retirement, and now I wish I had my job back." b. "It's been so stressful for me to have to depend on my son to help around the house." c. "I just heard my friend Al died. That's the third one in 3 months." d. "I keep forgetting which medications I have taken during the day."
d. "I keep forgetting which medications I have taken during the day."
A nurse is reviewing instructions with a client who has a hearing loss and has just started wearing hearing aids. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. "I use a damp cloth to clean the outside part of my hearing aids." b. "I clean the ear molds of my hearing aids with rubbing alcohol." c. "I keep the volume of my hearing aids turned up so I can hear better." d. "I take the batteries out of my hearing aids when I take them off at night."
d. "I take the batteries out of my hearing aids when I take them off at night."
A nurse is teaching a client about taking multiple oral medications at home to include time-release capsules, liquid medications, enteric-coated pills, and opioids. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. "I can open the capsule with the beads in it and sprinkle them on my oatmeal." b. "If I am having difficulty swallowing, I will add the liquid medication to a batch of pudding." c. "I can crush the pills with the coating on them." d. "I will eat two crackers with the pain pills."
d. "I will eat two crackers with the pain pills."
A security officer is reviewing actions to take in the even of a bomb threat by phone to a group of nurses. Which of the following statements by a nurse indicates understanding of proper procedure? a. "I will get the caller off the phone as soon as possible so I can alert the staff" b. "I will begin evacuating clients using the elevators." c. "I will not ask any questions and just let the caller talk." d. "I will listen for background noises."
d. "I will listen for background noises."
During new employee orientation, a nurse is explaining how to prevent IV infections. Which of the following statements by an orientee indicates understanding of the preventive strategies? a. "I will leave the IV catheter in place after the client completes the course of IV antibiotics." b. "As long as I am working with the same client, I can use the same IV catheter for my second insertion attempt." c. "If my client needs to use the rest room, it would be safer to disconnect his IV infusion as long as I clean the injection port thoroughly with an antiseptic swab." d. "I will replace any IV catheter when I suspect contamination during insertion."
d. "I will replace any IV catheter when I suspect contamination during insertion."
A nurse educator is conducting a parenting class for new parents of infants. Which of the following statements made by a participant indicates understanding of the instructions? a. "I will set my water heater at 130 degrees F." b. "Once my baby can sit up, he should be safe in the bathtub." c. "I will place my baby on his stomach to sleep." d. "Once my infant starts to push up, I will remove the mobile from over the crib."
d. "Once my infant starts to push up, I will remove the mobile from over the crib."
A nurse is preparing to administer digoxin to a client who states, "I don't want to take that medication. I do not want one more pill." Which of the following responses should the nurse make? a. "Your physician prescribed it for you, so you really should take it." b. "Well, let's just get it over quickly then." c. "Okay, I'll just give you your other medications." d. "Tell me your concerns about taking this medication."
d. "Tell me your concerns about taking this medication."
A nurse is evaluating teaching about nutrition with the parents of an 11-year-old child. Which of the following statements should indicate to the nurse an understanding of the teaching? a. "She wants to eat as much as we do, but we're afraid she'll soon be overweight." b. "She skips lunch sometimes, but we figure it's okay as long as she has a healthy breakfast and dinner." c. "We limit fast-food restaurant meals to three times a week now." d. "We reward her school achievements with a point system instead of a pizza or ice cream."
d. "We reward her school achievements with a point system instead of a pizza or ice cream."
A nurse is providing education for a client who has severe hypomagnesmia due to alcohol use disorder. The client is to receive magnesium sulfate. Which of the following information should the nurse include in the teaching? a. "You will receive magnesium in a series of intramuscular injections." b. "You should receive a prescription for a thiazide diuretic to take with the magnesium." c. "You should eliminate whole grains from your diet until your magnesium level increases." d. "You will have your deep-tendon reflexes monitored while you are receiving magnesium."
d. "You will have your deep-tendon reflexes monitored while you are receiving magnesium."
A nurse in an outpatient clinic is teaching a client who is in her first trimester of pregnancy. Which of the following statements should the nurse make? a. "You will need to get a rubella immunization if you haven't had one prior to pregnancy." b. "You can safely take over-the-counter medications c. "You should avoid any vitamin preparations containing iron." d. "Your provider can prescribe medication for nausea if you need it."
d. "Your provider can prescribe medication for nausea if you need it."
A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain? a. A client who has a broken femur and reports hip pain b. A client who has incisional pain 72 hr following pacemaker insertion c. A client who has food poisoning and reports abdominal cramping d. A client who has episodic back pain following a fall 2 years ago
d. A client who has episodic back pain following a fall 2 years ago
A nurse is assessing a client's neurosensory system. To evaluate sterognosis, the nurse should ask the client to close his eyes and identify which of the following items? a. A word she whispers 30 cm from his ear b. A number she traces on the palm of his hand c. The vibration of a tuning fork she places on his food d. A familiar object she places in his hand
d. A familiar object she places in his hand
A charge nurse is assigning rooms for the clients to be admitted to the unit. To prevent falls, which of the following clients should the nurse assign to the room closest to the nurses' station? a. A middle adult who is postoperative following a laparoscopic cholecystectomy b. A middle adult who requires telemetry for a possible myocardial infarction c. A young adult who is postoperative following an open reduction internal fixation of the ankle d. An older adult who is postoperative following a below-the-knee amputation
d. An older adult who is postoperative following a below-the-knee amputation
As part of the admission process, a nurse at a long-term care facility is gathering a nutrition history for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for the nurse to determine from the client's family? a. Body mass index b. Usual times for meals and snacks c. Favorite foods d. Any difficulty swallowing
d. Any difficulty swallowing
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. Beneficence
A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provides the body with the most energy? a. Fat b. Protein c. Glycogen d. Carbohydrates
d. Carbohydrates
A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include in her counseling? a. Carbon monoxide has a distinct odor b. Water heaters should be inspected every 5 years c. The lungs are damaged from carbon monoxide inhalation d. Carbon monoxide binds with homoglobin in the body
d. Carbon monoxide binds with homoglobin in the body
A nurse is caring for a family who is experiencing a crisis. Which of the following approaches should the nurse use when working with a family using an open structure for coping with crisis? a. Prescribing tasks unilaterally b. Delegating care to one member c. Speaking to the primary client privately d. Convening a family meeting
d. Convening a family meeting
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 about anticipated findings at this time. Which of the following findings should the nurse include in the discussion? a. Regular breathing patterns b. Warm extremities c. Increased urine output d. Decreased muscle tone
d. Decreased muscle tone
A nurse is preparing an instructional session for an older adult about managing stress incontinence. Which of the following actions should the nurse take first when meeting with the client? a. Encourage the client to participate actively in learning b. Select instructional materials appropriate for the older adult c. Identify goals the nurse and the client agree are reasonable d. Determine what the client knows about stress incontinence
d. Determine what the client knows about stress incontinence
A nurse uses a head-to-toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate? a. Confidence b. Perseverance c. Integrity d. Discipline
d. Discipline
A nurse is collecting data from a client who is receiving IV therapy and reports pain in his arm, chills, and "not feeling well." The nurse notes warmth, edema, induration, and red streaking on the client's arm close to the IV insertion site. Which of the following actions should the nurse plan to take first? a. Obtain a specimen for culture b. Apply a warm compress c. Administer analgesics d. Discontinue the infusion
d. Discontinue the infusion
A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crustings. The nurse should identify the client has manifestations of which of the following conditions? a. Allergic reaction b. Ringworm c. Systemic lupus erythematosus d. Herpes zoster
d. Herpes zoster
A nurse is providing education on how to check blood glucose levels to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should include which of the following instructions about transferring blood onto the reagent portion of the test strip? a. Smear the blood onto the strip b. Squeeze the blood onto the strip c. Touch the puncture to stimulate bleeding d. Hold the test strip next to the blood on the fingertip
d. Hold the test strip next to the blood on the fingertip
A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection? a. Prodromal b. Incubation c. Convalescence d. Illness
d. Illness
While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? a. Have the client hold his breath briefly and bear down b. Discontinue the fluid instillation c. Remind the client that cramping is common at this time d. Lower the enema fluid container
d. Lower the enema fluid container
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. Nonmaleficence
A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the interprofessional care team? a. Social worker b. Certified nursing assistant c. Registered dietitian d. Occupational therapist
d. Occupational therapist
A nurse in a primary care clinic is assessing a client who has a history of herpes zoster. Which of the following findings suggests the client is experiencing posterpetic neuralgia? a. Linear clusters of vesicles present on the right shoulder b. Purulent drainage from both eyes c. Decreased white blood cell count d. Report of continued pain following resolution of rash
d. Report of continued pain following resolution of rash
A client who has had a cerebrovascular accident has persistent problems with dysphagia (difficulty swallowing). The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team? a. Social worker b. Certified Nursing Assistant c. Occupational therapist d. Speech-language pathologist
d. Speech-language pathologist
An RN is making assignments for a practical nurse (PN) at the beginning of the shift. Which of the following assignments should the PN question? a. Assisting a client who is 24-hr postoperative to use an incentive spirometer b. Collecting a clean-catch urine speciment from a client who has a wound infection c. Providing nasopharyngeal suctioning for a client who has pneumonia d. Teaching a client who has asthma to use a metered-dose inhaler
d. Teaching a client who has asthma to use a metered-dose inhaler
A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? a. The flap closest to the body b. The right side flap c. The left side flap d. The flap farthest from the body
d. The flap farthest from the body
A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should the nurse include when explaining the procedure the the client? a. Eating more protein is optimal prior to testing b. One stool specimen is sufficient for testing c. A red color change indicates a positive test d. The specimen cannot be contaminated with urine
d. The specimen cannot be contaminated with urine
during rectal exam could notice a change in this vital sign
decreased pulse rate; vagal nerve stimulation can cause a reflex slowing of the heart rate
A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client
demonstrates the wound care procedure correctly.
Nursing diagnosis
describes human responses to health conditions or lfie
a time out
designated for vinal verification before surgery begins, a component of TJC universal protocol to prevent wrong site, wrong procedure, wrong person
indwelling catheter develops hematuria in last 4 hours What action
determine if receiving any anticoagualants
After completing an assessment and determining that a client has a problem, which action should the nurse perform next?
determine the etiology of the problem
Diagnostic Reasoning
determining a patient's health status after you have assigned meaning to the behaviors and symptoms presented
factors which affect safety
developmental considerations lifestyle mobility sensory perception knowledge ability to communicate physical health state psychosocial health state
Identify some common practices related to documentation, the last part of a complete assessment:
documentation should be timely thorough, and accurate. Record all observations. Pay attention to facts and be descriptive. Record objective information in accurate terminology. Do not generalize or form judgments
risk for perioperative positioning injury
during surgery the client may remain in one position for a prolonged period. The nurse must ensure that the client is protected from injury seconday to inapproriate positioning
the nurse is teaching a client proper use of an inhaler when should the client administer the medication
during the inhalation
venous VV and arterial AA
eleVate Veins dAngle Arteries for better perfusion
avoid any weight bearing on the left leg using a 3 point crutch gait for ambulation
encourage continued use of the 3 point gait by the client
ankle brachial index
ensure that you provide meticulous foot care
Explain how you would document a patient's nursing diagnosis:
enter the either on the written plan of care or in the agency's electronic health information record. List nursing diagnosis chronically, placing the highest nursing priority firs, date the diagnosis at time of entry, review list, and reevaluate priority
Present illness / health concerns
essential and relevant data about the nature and onset of symptoms
patient admitted to unit with pneumonia. She is able to ambulate on her own to the bathroom. What safety precautions should be taken for the patient?
explain the use of a call light keep the bed in the low locked position keep all side rails up when patient is not out of bed place a bedside commode near the bed ensure that the pathway to the bathroom is clear keep the patient's personal items in the bedside table
Curiosity
explore and learn more about a patient to make appropriate clinical judgments
pain on targus
external otitis
Biographical information
factual demographic data about the patient
head of bed positioning for post-craniotomy patient with infratentorial lesions
flat
which nursing diagnosis has the highest priority for the client in immediate post op period after cholectomy and ileosotmy
fluid and electrolyte imbalance
vesicles
fluid filled blisters
IV line
flush line before and after compatible IV solution
Decision making
focuses on problem resolution
Attainable
for a patient's health to improve he or she must be able to attain the outcomes of care that are set; mutually set attainable goals and outcomes
Nurse encourages male over 45 to get the PSA test
for prostate cancer screening
Nurse caring for dyspneic patient whose O2 sat is 90%. what position?
fowler's with both legs supported
buck's traction
fractured femur, transporting w/ traction-leave weights in place for duration of transport
safety
freedom from psychological and physical injury
Stage 3
full thickness loss involving damage to or necrosis of subcutaneous tissue that may extend to but not through underlying fascia
stage 4
full thickness skin loss to muscle and bone,
Diagnostic and laboratory provide:
further explanation of alterations or problems identified during the history and physical examination
surveillance cues specific potential indicators of bioterrorism attack
geographic clustering of illnesses-unusual age distribution for common diagnosis
Finding a client sitting on the floor, nurse calls for UAP to:
get a blood pressure cuff
preventing hypoxia during suctioning
give 100% oxygen before and after endotracheal suctioning
What is the sequence a nurse removes PPE?
gloves, gown, mask, wash hands
The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min? A. 42 gtt/min. B. 83 gtt/min. C. 125 gtt/min. D. 250 gtt/min.
gtt/min = 20gtts/ml X 1000 ml/4hrs X 1 hr/60 min Correct Answer: B
primary prevention against transmitting pathogens
handwashing
assessing a patient's sleep-rest pattern related to respiratory health
has trouble falling asleep awakens abruptly during the night has to sleep with the head elevated
To assess with menigitis for menigial irritation, how to position the head?
head and neck are flexed toward the chest
Health history
health care experiences and current health habits and lifestyle patterns
school aged safety concerns
help to avoid activities that are potentially dangerous provide interventions for safety at home, school, neighborhood, teach bicycle safety, teach about child abduction, wear seat belts
most frequent cause of hypovolemic shock postsurgical
hemorrhage
under 9 on braden scale
high risk
Risk nursing diagnosis
human responses to health conditions that may possibly develop in a vulnerable individual, family, or community
COPD barrel chest because of
hyperinflation of the lungs
temazepam
hypnotic
chronic renal failure, complains of tingling sensation around mouth and positive Chvosteck's sign
hypocalcemia
Medical diagnosis
identification of a disease condition
major risk factor for constipation
immobility; ask patient "how often do you get out of bed and walk"
Errors in interpretation and analysis of data:
inaccurate interpretation, failure to consider conflicting cues, insufficient number of cues, invalid cues, failure to consider cultural influences
hypovolemic shick
inadequate perfusion of tissues and cells from loss of circulatory fluid volume. Signs and symptoms are same as for hemmorage
paralytic ileus interventions
increase activity as soon as tolerable, perform actions to prevent hypokalemia, perform actions to maintain adequate tissue perfusion, administer GI stimulatns
what happens to the body when there is a fever
increased heat in the body so there is an increase in metabolism and o2 consumption results in: increased o2 demand, increased HR and Cardiac output
Following an episode of bacterial endocarditis a client develops mitral valve stenosis. The nurse recognizes that the client is at risk of pulmonary hypertension as a result of what process?
increased left atrial pressure
4 stages of infection
incubation - organisms growing and multiplying prodromal stage - person is most infectious, vauge, and nonspecific signs of disease full stage of illness - presence of specific signs and symptoms of disease convalescent - recovery
Disparities =
inequality
BY lymphedema
inform UAP no BP on that arm
in what sequence should the RN perform the abdominal assessment
inspection, auscultation, percussion, palpation
appropriate peak flow/meter
instruct patient to keep a record of peak flow meter numbers if symptoms of asthma are getting worse
administered a first dose of oral prednisone to a patient with asthma
intake and output
Interdisciplinary care plan
is designed to improve the coordination of all patient therapies and communication among all disciplines
A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate?
is disoriented to place and time.
When should the nurse conduct an Allen's test?
just before arterial blood gases are drawn peripherally
Define Evidence Based knowledge
knowledge based on research or clinical expertise
lumbar puncture position
lateral recumbent fetal position, keep patient flat 2-3 hours afterwards, sterile dressing, frequent neuro assessments
Enema positioning
left sided laying sim's
Crohns diet choice
low residue, low fat, high protein, high calorie, no dairy
deep vein thrombosis occurs in the
lower extremities and pelvis
Relieve abdominal cramping during enema
lower the enema bag roll the clamp to stop the enema until enema cramping subsides
in assessing breath sounds where should the nurse listen first
lung apices
organs and glands involved in homeostatic process of controlling body fluid composition and volume
lungs, heart, kidneys, adrenal glands, parathyroid glands, and pituitary gland
promote airway clearance in people with pneumonia
maintain adequate fluid intake splint the chest when coughing instruct patient to cough at end of exhalation
Chest tube column 125
mark container between 100 and 150
picture of chest tube vac
mark spot on the tube for the amount of 125ml of drainage
wet to dry dressing
mechanically debride the tissue
pathogens
microogranisms capable of causing illness
Diagnostic label:
name of the diagnosis as approved by NANDA, it describes the essence of the patient's response to health conditions
restraints
need to be assessed every 30 minutes; every 2 hours allow for ROM
abg draw
need to put the blood in a heparinized tube, make sure there are no bubbles, put on ice immediately after drawing
Angia
nitroglycerin
which assessment indicates resolution of Sub-q emphyesema
no crepitus palpated at site
Patient on neutropenic precautions
no flowers/plants in room no fresh veggies - cooked only avoid crowds and sick people
o2 flow rate for a COPD patient
no more than 2 liters by nasal cannula
Long term goal
objective behavior that is expected over a long period of time
when should restraints be used
only when alternatives have failed and you must keep patient or others safe or must continue therapy for overall patient good
common adverse effects of inhaled coritcosteroid
oropharyngeal candidiasis and hoarsness
The nurse identifies physical signs of trisomy 21 - down syndrome in a 3 month old infant during a well-child visit. Which focused assessments are most important for the nurse to complete/
overall health status hearing status vision status
urinary catheter in the wrong place
pain
pharyngeal rattle
palliative care
Handwashing sequence
palms, between fingers, dry off with paper towel, and turn off facet
Placement of wheelchair for transfer
parallel to the bed on the side of weakness
Contraindicates the removal of staples
partial dehiscence noted at the incision distal end
Stage 2
partial thickness skin loss involving epidermis and or dermis. Ulcer is superficial and presents an abrasion, blister, or shallow crater
Nursing is also,
patent-centered, meaning the patient drives the entire process.
Patient expectations
patient's understandings of why he or she is seeking health care
test to determine if patient is developing drug toxicity
peak and trough
Assessing placement of NG tube
ph lower than 4
petechiae
pinpoint red to purple skin discolorations that do not itchs
When entering a client's room the nurse discovers, the client is unresponsive and pulseless. The nurse starts cpr and calls for assistance. Which action should the nurse take next.
place cardiac leads on the patient
After assisting at the bedside with thoracentesis, the nurse should continue to assess the patient for
pneumothorax
intervention most appropriate to enhance oxygenation in a patient with unilateral malignant lung disease
positioning patient with good lung down
NEVER give POTASSIUM chloride IV push now
potassium chloride should never be administered IV should be diluted in IV solution
Impaired glucose tolerance 140-199 impaired fasting glucose 110-126 screen at 40 is FHx present encourage weightloss
pre-diabetes
diastolic
pressure when heart is relaxing
vital signs are the baseline for
problem solving
Inference
process of drawing conclusions from related pieces of evidence
Define reflective journaling:
process of purposefully thinking back or recalling a situation to discover the purpose or meaning
heat stroke
prolonged exposure to the sun and increased temperature overwhelm our heat loss mechanisms
DO NOT massage reddened areas of skin
promotes breakdown
serum lab value that reflects altered nutrition
protein of 5.0 g/dL range for normal serum protein is 6.4-8.3
The unit policy and procedure manual states that, for all clients admitted to the cardiac unit, if the client experiences chest pain, 1/150 grain nitroglycerin should be administered sublingually and an electrocardiogram should be obtained immediately. This is an example of a(n) _____________.
protocol
patient had a left total knee arthrosplasty on postoperative day 3 the patient complains of shortness of breath, slight chest pain, and that "something is wrong". Temperature is 98.4 BP 130/88, RR 36, oxygen saturation 91% on room air
pulmonary embolus from deep vein thrombosis
wound and protein purulent drainage
pus --> protein rich liquid product of necrotic tissue, made up of cells and cellular debris and is usually caused by an infection. can be thick, yellow, green, tan or brown
The HCP telephones the nurse and provides a verbal prescription for a client's persistent cough and pulmonary wheezing. The prescription includes a chest xray and antibiotic and a nebulizer treatment now and PRN, in what order should these interventions be implemented? First to last
read prescriptions back to HCP enter the verbal prescription in the electronic medical record administer the PRN nebulizer breathing treatment prepare the client for transpsort to radiology
Responsibility
refer to policy and procedure manual to review steps of a skill
sputum tenacious
refers to consistency
paralytic ileus
related to intestines during abdominal surgery, depresssant effect of anesthesia, and some medications on bowel motility signs/symptoms: development of persistent abdominal pain and cramping, firm distended abdomen, absent bowel sounds, failure to pass flatus, abdominal x ray
adult safety concerns
remind them of the effects of stress on lifestyle and health, counsel about unsafe health habits (reliance on drugs and alcohol), domestic violence
Spiritual history
represents the totality of one's being
kussmaul's respiration
respirations are abnormally deep, regular, and increased in rate. Common in diabetic ketoacidosis
Biot's respiration
respirations are abnromally shallow for 2 or 3 breaths followed by irregular period of apnea
priority nursing assessment in car of a patient with a tracheostomy
respiratory rate and oxygen saturatoin
common portals of exit
respiratory, GI, GU, breaks in skin, blood and tissue
earliest sign of hypoxia
restlessness
Braden Scale
risk for pressure sores; the braden scale assess many risk factors that contribute to pressure sores. The factors in nutrition, ability to move, degree of activity, moisture, sensory perception, and risk for friction/shear. The lower sore indicates a higher risk for pressure ulcers
patient on fall precautions
room close to nurse station assist w/ ambulation wear non skid foot wear sign posted on patient door bed alarm on bed in low / locked position arm band
insulin admin teaching
rotate sites of injection, no aspiration, 90 degree angle
Administering med IV through central venous catheter with hep lock. Order?
saline, med, saline, hep
gate control theory of pain
says pain has emotional cognitive components in addition to physical. There are gating mechanisms among the CNS that can regulate or even block pain impulses. The pain passes when the gate is opened, and is blocked when the gate is closed. C fibers open gates, A delta fibers close gate
industry vs inferiority
school age 5 to 12
performing a surgical hand scrub prior to entering the operating room
scrape under nails w/ nail pick rinse from the fingertips to the elbow use a soapy brush to scrub the hands cleanse the arm with a lathered brush
William's position
semi fowlers with knees flexed to relieve lower back pain
psychological impact of isolation
sense of loneliness, social relationships disrupted, altered body image, limited sensory contact
isolation
separation and restriction of movement of ill persons with contagious disease
Data cluster:
set of signs or symptoms gathered during assessment that help you group the together in a logical way
goal
should be a broad statement that includes in positive terminology the intended effect of the planned interventions
GI bleeding - NGT suctoin
show the patient a nasogastric tube and explain reasons for low intermittent suction
Incentive spirometer use
sit upright exhale insert mouthpiece inhale for 3 seconds, then hold for 10 seconds
Patient on bleed precautions
soft bristle toothbrush electric razor only to shave avoid IM injections, use small needles when necessary and hold pressure for 5 minutes no straining with BM
papules
solid elevated lesions
Patient Centered goal
specific and measurable in response to a nursing intervention
non blachable red intact
stage 1
vrsa
staph infection that is resistant to vancomycin treatment; worse than MRSA
IV med incompatible
start a new line
what source contains legal requirements nurses must follow to protect pt in nurse-patient relationship?
state nurse practice acts
Review of systems (ROS)
systematic approach for collecting the patient's self-reported data on all body systems
The nursing process is:
systemic, dynamic, interpersonal, outcome oriented, and universally applicable.
first sound when listening to Korotokoff sounds
systolic pressure
Which instructions should the nurse convey to help prevent VTE in patient
teach patient to dorsal flex and plantar flex his feet while in bed and chair explain that enoxaparin injections will be administered routinely
action the rn implements to prevent muscle atrophy
teach patient to perform exercises such as gluteal sets and quadriceps every 5 times every 2 hours
adolescent safety concerns
teach safe driving skills, avoidance of tobacco and alcohol, risk of infection with body piercing, teach about violence
Vitamin K
technnique 25 gauge, 58 inch needle to administer in either the vastus laterials
Measurable
terms describing quantity, frequency, length, or weight, allow the nurse to evaluate outcomes precisely
nurse notices clear nasal drainage in patient newly admitted with facial trauma and nasal fracture
test the drainage for presence of glucose
what statement by a client 24 hours post thyriodectomy requires an immediate intervention by the nurse?
the dressing over my incision feels too tight
nurse assess a patient with SOB for evidence of long-standing hypoxemia by inspecting:
the fingernails and their base
Consultation is a process in which:
the nurse seeks the expertise of a specialist to identify ways to handle problems in patient management or the planning and implementation of therapies
Blended competencies =
the set of intellectual, interpersonal, technical, and ethical/legal capacities needed to practice professional nursing
The ultimate authority of nursing practice is . . .
the state board of nursing
Wheelchair bound with a positive thomas test after administration to the rehab unit
there may be a delay in the rehab process
what system in body regulates temperature
thermoregulatory center in the hypothalamus regulates temperature; center initiates responses to procedure or conserve body heat or increase heat loss
to prevent pressure at nigh
thirty degree lateral inclined position
which assessment finding reflects signs of possible thrombophlebitis that should be reported to the HCP
unilateral calf edema
When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the
upper torso
While preparing a sterilized field prior to doing sterile dressing change, the nurse drops a sterile gauze pan on the edge of the edge of the sterile field. What is the best nursing action?
use a sterile glove to remove the contaminated gauze
nurse delegation to UAP for positioning patient to prevent DVT
use two pillows and place one lengthwise under each calf
Student care plan
useful for learning problem solving techniques, nursing process, skills of written communication
IM injection in 18 month old
vastus lateralis
patient with acute exacerbation of COPD needs to receive precise amounts of oxygen
venturi mask
Define concept mapping
visual representation of patient problems and interventions that shows their relationships to one another
A concept map is:
visual representation that allows you to graphically show the connections between a patient's many health problems
petaling
you can petal the rough edges of a plaster cast with the tape to avoid skin irritation
