Prep U Questions

A staff nurse comments to the charge nurse that it is unnecessary to know how to formulate nursing diagnoses because the computerized documentation system generates them automatically. What is the most appropriate response by the charge nurse?

"A nurse is still responsible for using critical thinking to determine the validity of the nursing diagnoses generated."

Paramedics arrive in the emergency department with a client who was in a motor vehicle collision. The paramedic reports that the driver was restrained, the car was traveling about 30 miles per hour (48 km/hr), and the air bags were not deployed. The paramedic continues to report that the car was struck from behind and that all individuals in the car were able to self-extricate. Which statement made by the nurse is verifying the report from the paramedic?

"All of the people got themselves out of the car?"

Which safety tip could the nurse give to parents to help decrease the risk of the leading cause of injury or death in children 1 to 4 years of age?

"Always provide close supervision for young children when they are in or around pools and bathtubs."

A client arrives at a crisis center in a state of bipolar mania. The client has a flight of ideas and it is difficult for the nurse to obtain an adequate intake assessment. Which statement or question will elicit the most specific information?

"Are you allergic to any medications?"

The nurse is collecting health data and avoids using closed-ended questions. Which are examples of closed-ended questions? Select all that apply.

"Are you ready to get out of bed?" "Do you smoke cigarettes?" "Is there any chance you might be pregnant?" "Does it hurt when I touch you here?"

The nurse is discussing car safety with the mother of a 6-year-old child. The child's mother questions the need for the use of special car seats for her child. What information can be provided to her?

"At the age of 6 your child should be using a booster seat."

How should a nurse best document the assessment findings that have caused the nurse to suspect that a client is depressed following a below-the-knee amputation?

"Client states, 'I don't see the point in trying anymore.'"

The nurse is performing an admission interview with a new client diagnosed with acute coronary syndrome. For the nurse to obtain information and allow the client free verbalization, which question would elicit the most information?

"Could you tell me more about how you are feeling right now?"

The newly hired nurse is collecting assessment data for an upcoming surgical procedure from a client who speaks English as a second language. Which statement or question made by the newly hired nurse would indicate to the nurse manager that intervention is needed?

"Do you have any questions about your cholecystectomy?"

The nurse is caring for a client who ascribes to the theory of animism. When attempting to explain this theory to other staff members, the nurse should state:

"Everything in nature is alive with invisible forces."

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

"Feel like a woman...."

A nurse is discussing cataract treatment with a client. Which statement by the nurse would be most therapeutic?

"Have you ever thought of laser surgery?"

The nurse is taking the apical pulse of a 6-month-old infant. Upon completion, the nurse tells the parent the baby's pulse is 140 beats per minute. The parent is concerned, stating, "That seems kind of high!" The nurse responds:

"I know it seems fast, but normal infant heart rates are 100-160 beats per minute."

A nurse is caring for a client who is newly diagnosed with terminal cancer. The nurse enters the client's room and finds the client sitting in the dark crying. Which statement conveys empathy by the nurse?

"I know this is hard for you. Is there any way I can help?"

The expected outcome for a client with a new diagnosis of rheumatoid arthritis (RA) is: "Client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met?

"I should call my health care provider if I have a sore that won't heal."

A nurse is asking a colleague about a situation. Which statement demonstrates assertive communication?

"I think there is a better way to handle this."

A nurse is obtaining a history from an adult female client. When the nurse asks how many times the client has been pregnant, the client answers, "I have four kids." Which statement, made by the nurse, seeks clarification of the original question?

"I understand you have four kids; how many times have you actually been pregnant?"

The nurse is conducting discharge teaching for a caregiver and a toddler. Which statement by the caregiver indicates the need for additional teaching?

"I will check my text messages while my child is in the tub."

The child of a client who just died in a hospice unit arrives and asks, "May I please stay and sit at the bedside? I really wanted to be here so my dad would not die alone." Which statement made by the nurse best demonstrates the use of empathy?

"I will close the door so you can spend some quiet time at the bedside."

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement demonstrates that teaching has been effective?

"I will rescue clients from harm before doing anything else"

The client is talking to the nurse about recent health problems of immediate family members and the strain the client has been under trying to care for them. The client begins to cry. What response by the nurse demonstrates the most empathy?

"Just take your time. I am listening."

The nurse is attempting to provide anticipatory guidance for the parents of an 18-month-old child. Which statement would be best for the nurse to make?

"Keep all medications in a locked cabinet."

The nurse is talking with a client who is thinking about obtaining a second opinion regarding the surgeon's recommendation for surgery. Which response by the nurse is considered an advocacy response?

"Let us know if we can answer any further questions after you obtain your second opinion."

What is the best response by the nurse when a client asks about the side effects of using nasal spray?

"Long-term use of nasal sprays can cause rebound nasal congestion."

A school nurse is conducting a safety seminar with students in 6th grade. Which teaching point is most important?

"Make sure that you have smoke detectors in your house and that they're in working order."

A client who has been prescribed an inhaler points to the spacer and asks, "What is this for?" What is the appropriate nursing response?

"Medication stays in the chamber so you can continue to inhale it."

A nurse is calling a physician to communicate a change in the client's condition. According to the ISBARR format for handoff communication among health care personnel, which is the most appropriate way to begin the conversation?

"My name is Sue Smith, RN, and I am calling regarding Mrs. Jones in room 356 at Jefferson Hospital."

A client asks an RN to prescribe a medication for pain. What is the best answer by the nurse?

"Only advanced practice registered nurses have prescriptive authority."

A nurse is caring for a client experiencing biliary colic from uncomplicated cholelithiasis. The client asks, "My doctor says I should have surgery to remove my gallbladder. Do you think it is really necessary?" What is the nurse's best response?

"Share with me the advantages and disadvantages of your options as you see them."

A client is reluctant to undergo surgery and is discussing it with the nurse. Which response by the nurse would reflect an authoritarian approach?

"Surgery is your only option. You need this operation."

A client reports to a primary care physician with aggravated chest pain. The physician orders a stress test. The client tells the nurse that the client does not want to take the test and would prefer instead to continue taking medication a little longer. Understanding that the client is anxious, what is the most appropriate response by the nurse?

"Tell me more about how you're feeling"

A nurse is caring for a client with a diagnosis of metastatic lung cancer. The nurse finds the client sitting in a chair while staring out the window. The nurse conveys caring by saying:

"Tell me what is on your mind."

A nurse tells the charge nurse about difficulty obtaining the client's cooperation in providing care. What would be the charge nurse's most appropriate response?

"The best way to obtain your client's cooperation is by first obtaining your client's trust."

A client is scheduled for thoracentesis. The nurse assesses that the client appears anxious about the procedure and needs honest support and reassurance. What is the most appropriate response by the nurse to this client?

"The needle causes discomfort or pain when it goes in, but I will be by your side throughout and will help you hold your position."

When the preoperative client tells the nurse that the client cannot sleep because the client keeps thinking about the surgery, an appropriate reflection of the statement by the nurse is:

"The thought of having surgery is keeping you awake."

A nurse has developed strong rapport with the spouse of a client who has been receiving rehabilitation following a debilitating stroke. The spouse has just been informed that the client is unlikely to return home and requires care that can only be provided in a facility with constant nursing care. The client's spouse tells the nurse, "I can't believe it's come to this." How should the nurse best respond?

"This must be very difficult for you to hear. How do you feel right now?"

Which statement indicates that a family understands the teaching that has been provided by the nurse related to car seat safety for their 3-year-old child?

"We place our child in a front-facing car seat in the back seat of the car."

The nurse is communicating with a client following a routine physical examination. Which statement best demonstrates summarization of the appointment?

"We reviewed your plans for your new diet and medications. Do you have any other questions?"

A client with a cardiac dysrhythmia was recently prescribed metoprolol and is at a follow-up appointment at the cardiologist's office. The client tells the nurse, "I feel depressed, tired, and I have no desire to exercise." To determine a cause-and-effect relationship, the nurse should ask:

"Were you tired and depressed before starting the new medication?"

A 70-year-old client had a cholecystectomy 4 days ago. The client's daughter tells the nurse, "My mother seems confused today." Which question would be best for the nurse to ask to assess the client's orientation?

"What day of the week is it?"

During an admission intake assessment, a nurse uses open-ended questions to gather information. An example of an open-ended question is:

"Why did your physician send you here to be admitted?"

The nurse completes the admission process of a client to an acute care facility. Which statement by the nurse demonstrates the communication technique of focusing?

"You are hoping to figure out the cause of your extreme fatigue during this hospital stay."

A pregnant woman with a history of genital herpes infection who is near term asks the nurse why she must have a cesarean section when she has not had an outbreak in a "long time". The nurse responds:

"You may have infection in your birth canal that you are unaware of."

A nurse is assessing vital signs on a pregnant client during a routine prenatal visit. The client states, "I know labor will be so painful, it sounds awful. I am sure I will not be able to stand the pain; I really dread going into labor." What is the best response from the nurse?

"You're worried about how you will tolerate the pain associated with labor."

A nurse is administering a subcutaneous injection to a client. What is the common maximum volume of a subcutaneous injection?

1 mL

The nurse is preparing to administer an allergy test intradermally. At what angle will the nurse plan to insert the needle into the client?

10 to 15 degrees

In what time period did nursing care as we now know it begin?

18th to 19th century

The nurse has completed an assessment and notes that the client's blood pressure is 132/92 mmHg. What is this client's pulse pressure?

40 mmHg

Unintentional injuries are a major cause of disability and death in the United States. For adults, where do unintentional injuries fall on the list of leading causes of death?

5th

The nurse is preparing to administer insulin to an obese client. At what angle will the nurse plan to insert the needle into the client?

90 degrees

The nurse, while admitting an older adult client, charts, "The client does not respond when I speak while standing on the client's right side." This statement is an example of:

A cue

A nurse is assessing a client admitted to the hospital with reports of difficulty urinating, bloody urine, and burning on urination. What is a priority assessment for this client?

A focused assessment of the specific problems identified

Which scenario is an example of a time-lapse reassessment?

A nurse assesses a client with mobility issues to see how the client is doing with fall prevention strategies they practiced before.

A nurse is demonstrating collegiality in professional practice. Which behaviors practiced by the nurse correlate with this standard of practice? Select all that apply.

A nurse helps a colleague write a journal article. A nurse encourages a colleague to join the hospital journal club. A nurse encourages a colleague to join the American Nurses Association (ANA)

In which situation would the SBAR technique of communication be most appropriate?

A nurse is calling a physician to report a client's new onset of chest pain.

Nurses use social media to share ideas, develop professional connections, access educational offerings and forums, receive support, and investigate evidence-based practices. Which is an example of the proper use of social media by a nurse?

A nurse uses a disclaimer to verify that any views the nurse expresses on Facebook are the nurse's alone and not the employer's.

Which nurse would most likely be the best communicator?

A nurse who easily develops a rapport with clients

Which statement is true regarding addressing a priority problem?

A priority problem requires a nursing intervention before another problem is addressed.

The nurse caring for a client with obesity would like to address the possible health problems that can develop related to obesity. To plan care for this client, what type of nursing diagnosis would the nurse formulate?

A risk nursing diagnosis

A nurse is caring for an 18-month-old client after a tracheostomy. The is recovering well and noted a desire to be more active. The nurse selects a toy from the playroom for the client to play with. Which toy is most developmentally appropriate?

A rocking horse

Research is included as an essential component of nursing by which of the following organizations? (Select all that apply.)

ANA International Council of Nurses Nursing specialty organizations

After hearing a presentation about the American Nurses Association (ANA), a nurse decides to join the organization based on the understanding that:

ANA aims at fostering high standards of nursing in the United States.

A nurse is reading a research article from a nursing journal. The nurse is aware that the opening paragraph summarizing the article and the research findings is a good place to start. What part of the article is the nurse reading?

Abstract

The acronym RACE is commonly taught as a means for remembering priorities for action during a fire. The "A" in this acronym stands for which of the following?

Activate the fire alarm and notify the appropriate person.

A nurse is treating a client with congestive heart failure. The client reports having difficulty walking up the stairs at home and barely being able to walk to the store. Which is an accurate actual nursing diagnosis for this client?

Activity Intolerance related to congestive heart failure as evidenced by inability to walk up and down stairs

A nurse is using Gordon's functional health patterns as an organizing framework for client assessment. The client has significant problems related to breathing, for which the nurse identifies several nursing diagnostic labels, including Ineffective Breathing Pattern and Impaired Gas Exchange. The nurse understands that these nursing diagnoses would be organized under which functional pattern?

Activity exercise

After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type?

Actual

"Acute Pain related to instillation of peritoneal dialysate as evidenced by client wincing and grimacing during procedure, client description of experience as 'stabbing'" is an example of which type of nursing diagnosis?

Actual nursing diagnosis

The nurse is caring for a client who underwent abdominal surgery today. Which nursing diagnoses would be appropriate for the nurse to identify for this client? Select all that apply.

Acute Pain related to disruption of skin tissues secondary to abdominal surgery Risk for Infection related to altered tissue integrity Impaired Mobility related to fear of pain Risk for Constipation related to immobility

A nurse is caring for a client who began taking the antidepressant paroxetine 2 weeks ago. The client recently began giving away prized possessions and tells the nurse, "My mind is made up, I can't do this any longer." What is the best action by the nurse to incorporate this information into the plan of care?

Add the nursing diagnosis: Risk for Self-Harm.

The nurse is preparing to interview a client who demonstrates significant abdominal pain and rates the pain at 10 on a 0 to 10 pain scale. What action by the nurse can improve the outcome of the interview?

Administer prescribed pain medication prior to conducting the interview.

The nurse is preparing a medication from a vial and contaminates the plunger after the medication is drawn into the syringe. What should the nurse do next?

Administer the medication as prescribed

A nurse is preparing to conduct a research study and uses the PICO format to develop the foreground question which is: "In adults, does reducing salt intake, compared to no change in salt intake, lower blood pressure?" The nurse identifies the "P" as:

Adults

Which statement by a new nurse regarding validation of data collected during client assessment indicates a need for further training?

All data collected need to be validated.

Based on its jurisdiction, which actions may a state licensing board of nursing take? Select all that apply.

Allow graduates of approved schools of nursing to take the NCLEX License nurses during the lifetime of the holder Deny licensing due to criminal actions

Which is an appropriately stated nursing intervention?

Ambulate 30 ft (9 m) twice a day with the assistance of a walker.

The first nursing journal owned, operated, and published by nurses was:

American Journal of Nursing

Which organization has established standards that help the nurse determine which clinical actions fall under the scope of nursing practice?

American Nurses Association

Which authoritative statements guide current professional nursing practice?

American Nurses Association Standards of Nursing Practice

Which client situation most likely warrants a time-lapse nursing assessment?

An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit.

A nurse is caring for an older adult client who is scheduled for a cystoscopy the next day to determine the cause of an overdistended bladder. The client expresses being nervous and informs the nurse that this the first time that the client has been admitted to a health care facility for an illness. Which diagnostic label would the nurse use to formulate the nursing diagnosis?

Anxiety

The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse?

Apply a nonparticulate (N-95) respirator when entering the room.

A community health nurse has been visiting a diabetic client whose morning fasting glucose levels are constantly elevated. Upon further assessment, the nurse determines that the client's spouse does not understand how to prepare meals following the prescribed diabetic diet. Using Dorothea Orem's Self-Care Theory, how can the nurse help meet the needs of this client?

Arrange an evaluation appointment with a dietitian.

A nurse is planning care for an adult client with severe hearing impairment who uses sign language and lip reading for communication and who has a new diagnosis of cancer. Which nursing action is most appropriate when establishing the plan of care for this client?

Arrange for a sign language interpreter when discussing treatment.

When is the best time for a nurse to take a client's health history?

As soon as possible after a client presents for care

A nurse educator is teaching a student nurse how to choose the correct needle for an injection. Which guidelines for needle selection might they discuss?

As the gauge number becomes larger, the size of the needle becomes smaller.

A nurse at the health care facility needs to administer an otic application for a client with an earache. What should the nurse do after instilling the prescribed eardrops in the client's ear?

Ask the client to maintain the position for some time.

A nurse suspects that the client with Crohn's disease does not understand the medication regimen or diet modifications required to manage the illness. What is the nurse's most appropriate action?

Ask the client to verbalize the medication regimen and diet modifications required.

During examination a client becomes very tired but still needs to answer questions so that the nurse has sufficent data for planning care. Which action by the nurse would be most appropriate in this situation?

Ask the client whether it is okay to interview the client's spouse for the answers to the interview questions.

The nurse overhears an older adult client's son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers. What should the nurse do about this observation?

Ask to examine the patient alone in order to speak with her privately

A nurse is caring for an older adult client hospitalized following a hip fracture. Which actions by the nurse will promote the development of a therapeutic relationship? Select all that apply.

Asking the client when the client would like to have the bed linens changed Encouraging the client to talk about the client's life

Which action would the nurse perform in the assessment phase of the nursing process?

Asking the client whether the client has cultural preferences

A nurse states the following to another nurse who is constantly forgetting to wash hands between clients: "It looks like you keep forgetting to wash your hands between clients. It's really not safe for your clients. Let's think of some type of reminder we can use to help you remember." This communication is an example of what type of speech?

Assertive

The nursing process includes step(s)? Select all that apply.

Assess Plan Implement Evaluate

A nurse is completing a health history on a client who has a hearing impairment. Which action should the nurse take first to enhance communication?

Assess how the client would like to communicate

The nurse is preparing to administer a blood pressure medication to a client. To ensure the client's safety, what is the priority action for the nurse to take?

Assess the client's blood pressure to determine if the medication is indicated.

The nurse is performing care for a client in the end stage of cancer. How can the nurse best facilitate the client and family's ability to cope? Select all that apply.

Assist the client with activities of daily living (ADLs). Assist the client and family with the preparation for end-of-life. Refer the client and family to hospice services.

The nurse and client have written the following outcome measure: "The client will eat at least 80% of each meal offered by 3/2." When should the nurse collect information to evaluate this outcome?

At the completion of each meal

A nurse suspects that a client may have a hearing problem. The nurse should attempt to consult:

Audiologist

A nurse attempts to count the respiratory rate of a client via inspection and finds that the client is breathing at such a shallow rate that it cannot be counted. What is an alternative method of determining the respiratory rate for this client?

Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2.

Which nursing action can be categorized as a surveillance or monitoring intervention?

Auscultating of bilateral lung sounds

Knowledge gained from someone with a great deal of perceived experience is which type of knowledge?

Authoritative knowledge

The nursing is caring for several clients. Which intervention can the nurse direct the unlicensed assistive personnel (UAP) to perform?

Bathe a client with stable angina who has a continuous IV infusing.

A homeless client in the public health clinic has a strong body odor and is wearing clothes that are visibly soiled. What nursing diagnosis would be most appropriate for the nurse to identify?

Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor

A nurse is completing a health history with a newly admitted client. During the interview, the client presents with an angry affect and states, "If my doctor did a good job, I would not be here right now!" What is the nurse's best response?

Be silent and allow the client to continue speaking when ready.

A nurse and an older adult client with chronic back pain are beginning to communicate. What activity should the nurse focus on at this point?

Being sensitive to the client's emotional barriers

The nurse is performing an assessment on a newly admitted client and understands the importance of validating all data. When is the best time to validate such data?

Both during the collection and at the end of the collection

A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination?

Bowel incontinence

Nurses understand the problem that clients have when they are repeatedly asked the same questions. To best avoid this problem, which intervention should nurses perform when beginning to collect assessment data?

Carefully review the client's records

A nurse develops the following foreground question using the PICO format in preparation for a research study: "In overweight clients, how do chromium supplements compared to no supplements help with weight loss?" Which part of the question reflects the intervention?

Chromium supplements

Which is the best source of information for the nurse when collecting data for an assessment?

Client

A nurse is assessing a client admitted to the hospital with reporting left-sided weakness and difficulty speaking. Which documented statement best represents the data that should be collected in a nursing assessment?

Client is unable to communicate basic needs and cannot perform hygiene measures with left hand.

A client with end-stage chronic obstructive pulmonary disease (COPD) has the nursing diagnosis "Activity Intolerance." Which expected client outcome most directly demonstrates resolution of the problem?

Client will alternate rest periods with exercise throughout the day.

The nurse should consider which client aspect as nonverbal communication?

Client's tone of voice

The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply.

Client-centered care Teamwork and collaboration Quality improvement (QI)

A nurse is planning to pursue further education in the hopes of becoming an expert in geriatric nursing who carries out direct care. For which expanded career role is the nurse preparing?

Clinical nurse specialist

"The client will verbalize appropriate cast care on discharge" represents which type of outcome?

Cognitive

Which type of health problem requires both physician- and nurse-prescribed actions to address?

Collaborative health problem

While developing a plan of care for a client, what should the nurse do before selecting a nursing diagnosis?

Collect client subjective and objective data.

Which group of terms best defines assessing in the nursing process?

Collection, validation, communication of client data

During the course of any given day of work in the acute care setting, the nurse may need to perform which roles? Select all that apply.

Communicator Counselor Teacher

The nurse is preparing to administer oral medication to a client. Which is the first action the nurse will take?

Compare the medication administration record (MAR) with the written medical order.

A client with congestive heart failure has dyspnea while ambulating to the bathroom. The nurse selects the nursing diagnosis of "Activity Intolerance" to address this health problem. Which etiology would be appropriate to select for this nursing diagnosis?

Compromised oxygen transport

A group of objects with relationships is which?

Concept

A nursing theory differs from a theoretical framework in which way?

Concepts and propositions are more specific

Which is true of concepts?

Concepts describe objects, properties, and events and the relationships among them.

A client reports not having a bowel movement for 7 days, followed by a day of small, loose stools. How does the nurse define the health problem?

Constipation related to irregular evacuation patterns

A newly graduated nurse is unable to determine the significance of data obtained during an assessment. What would be the nurse's most appropriate action?

Consult with a more experienced nurse.

A nurse who recently graduated is performing an assessment on a client who was admitted for nausea and vomiting. During the assessment, the client reports mild chest pain. The nurse does not know whether the chest pain is related to the gastrintestinal symptoms or should be reported to the physician. Which action should the nurse perform next?

Consult with another nurse

While performing an assessment, the nurse recognizes that the nurse's own personal biases may be interfering with the collection of data. What step should the nurse take to ensure that the information is factual and accurate?

Consult with another nurse for that colleague's description of the assessment or observations.

Which is a skill appropriate to use in therapeutic communication?

Control the tone of the voice to avoid hidden messages.

Which guideline should the nurse follow when including interventions in a plan of care?

Date the nursing interventions when written and when the plan of care is reviewed.

The client, who is 8 weeks pregnant as the result of a rape, tells the nurse, "I do not want to have this baby, but I have always believed that abortion is a sin. I don't know what to do." What nursing diagnosis would be most appropriate for the nurse to formulate?

Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement

The nurse has completed an intervention with a client. There is no visible soiling on the nurse's hands. Which technique is recommended by infection control practice standards for hand hygiene?

Decontaminate hands using an alcohol-based hand rub.

A nurse researcher develops a foreground question in preparation for conducting a research study. The question is: "In clients with intravenous catheters, how does replacing administration sets every 72 hours (h) compared with other frequent intervals (24h, 48h, or 96h) decrease infection rates?" Applying the PICO framework, which part of the statement reflects the "O"?

Decrease infection rates

Which nursing diagnoses are stated correctly? Select all that apply.

Deficient Fluid Volume related to abnormal fluid loss Nutrition Deficit related to inability to eat a balanced diet

Which component of a nursing diagnosis gives additional meaning to the nursing diagnosis?

Descriptors

A client's eMAR states that two medications are due at the same time, both of which are available in vials and are to be administered by injection. What is the nurse's most appropriate action?

Determine the compatibility of the two drugs by consulting clinical resources.

Which describes the best approach for the development of nursing diagnoses?

Develop nursing diagnoses from clusters of significant data.

While caring for a client admitted with a Clostridium difficile infection, the nurse notes that the client has had three loose bowel movements in 3 hours. What would be the most appropriate nursing diagnosis to address this health problem?

Diarrhea related to infectious processes secondary to C. difficile infection as evidenced by three loose bowel movements in 3 hours

The new nursing graduate is concerned about some of the critical changes that will be occurring in nursing. What changes does the nurse anticipate will impact nursing care?

Difficulty for nurses to remain current in a rapidly changing medical and technology environment

The nurse is setting up a sterile field to perform a catheterization when the client touches the end of the sterile field. What would be the nurse's next appropriate action?

Discard the sterile field and the supplies and start over.

The nurse is preparing a sterile field for a bedside procedure. During preparation, the client reaches over the field for the water pitcher. What would be the best action by the nurse?

Discard the supplies and field and prepare a new sterile field.

The nurse has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, "I am not ready to deal with this now. I am feeling overwhelmed." What is the nurse's most appropriate action?

Discontinue education and attempt at a different time

A client tells the nurse, "My doctor has told me I have to have a blood transfusion, but I am a Jehovah's Witness and I can't take one." What is the nurse's most appropriate intervention?

Discuss possible alternatives to a blood transfusion with the physician.

The nurse has finished caring for a client on contact precautions. Which nursing action regarding the stethoscope used to auscultate this client's lungs and bowel sounds is appropriate?

Disinfect it with alcohol swabs.

A client undergoing chemotherapy for breast cancer has lost all hair. The client states, "I cannot stand to see myself without hair. I am disgusting." What would be the most appropriate nursing diagnosis for the nurse to use to address this client's problem?

Disturbed Body Image related to loss of hair

When assessing a client's respiratory rate, the nurse should take which action?

Do it immediately after the pulse assessment so the client is unaware of it.

Which action should the nurse take during the evaluation phase of the nursing process?

Document reassessment of pain after medication administration.

A child is playing soccer and is involved in a head-to-head collision with another player. Which assessment findings should the nurse be alert to that may indicate a concussion? Select all that apply.

Drowsiness, headache, vomiting

Which is a focus of medical research rather than nursing research?

Drug metabolism

Which statement describes diastolic blood pressure?

During ventricular relaxation, blood pressure is due to elastic recoil of the vessels

A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent?

Educational

The nurse is performing an extensive dressing change on a client with burns. The nurse explains each step as it is being performed. The nurse is acting in which role by providing explanation of each step?

Educator

A family has lost a member who was treated for leukemia at a nursing unit. The nurse provides emotional support to the family and counsels them to cope with their loss. Which quality should the nurse use in this situation?

Empathy

Which quality in a nurse helps the nurse to become effective in providing for a client's needs while remaining compassionately detached?

Empathy

What is the best nursing intervention to promote health in a client at risk for heart disease?

Emphasizing a client's strengths to encourage weight loss

The nurse is visiting a hospice client in the client's home. The client is explaining difficulties with a home infusion pump. By making statements such as "I see" and "go on" during the conversation, the nurse is using which therapeutic nurse-client communication technique?

Encouraging elaboration

When administering a subcutaneous injection to a client, the needle pulls out of the skin when the skin fold is released. What would be the appropriate next action of the nurse in this situation?

Engage safety shield on needle guard and discard needle appropriately.

The nurse is preparing to submit a research project to the institutional review board (IRB). The nurse understands that which is the purpose of the IRB?

Ensure ethical treatment of all participants

A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order?

Ensure that two fingers can be inserted between the restraint and the client's extremity.

A nurse who works in a pediatric practice assesses the developmental level of children of various ages to determine their psychosocial development. These assessments are based on the work of:

Erikson

In a helping relationship, the nurse would most likely perform what action?

Establish communication that is continuous and reciprocal.

When looking at a model for evidence-based practice, what is the final step of the process?

Evaluating practice change

What nursing activity forms the bridge between theory and practice?

Evidence-based research

Which activity best helps the nurse apply theory to practice?

Evidence-based research

A nurse is discharging a client and thus terminating the nurse-client relationship. Which action should the nurse perform in this phase?

Examine goals of the relationship to determine whether they were achieved

A client has been admitted with symptoms of shortness of breath on exertion, edematous lower extremities, extreme fatigue, and hypertension. Which are priority nursing diagnoses? Select all that apply.

Excess Fluid Volume Decreased Cardiac Output Activity Intolerance

While assessing a client, the nurse notices that the client seems to be distracted from the questions being asked. The nurse attempts to identify factors that may be affecting the communication. What would the nurse identify as an internal influencing factor?

Experience

A nurse researcher is examining the cause-and-effect relationship between the consumption of tap water containing minimal amounts of bleach, and the incidence of cancer in rats. The research is taking place in a laboratory setting. What type of quantitative research is being used based upon this description?

Experimental research

When assessing a client's nonverbal communication, the nurse should assess which aspect as being the most expressive?

Facial expressions

A client is distraught because a recent computed tomography (CT) scan shows that the client's colon cancer has metastasized to the lungs. Which nursing aim should the nurse prioritize in the immediate care of this client?

Facilitating coping

The client is an 18-month-old in the pediatric intensive care unit. The client is scheduled to have a subgaleal shunt placed tomorrow, and the client's mother is quite nervous about the procedure. The nurse tells the client's mother, "The surgeon has done this a million times. Your son will be fine." This is an example of what type of nontherapeutic communication?

False reassurance

Which mask should the nurse don when caring for a client with tuberculosis?

Filtered respirator

Priority setting is based on the information obtained during reassessment and is used to rank nursing diagnoses. Each factor contributes to priority setting except which?

Finances of the client. The client's condition, time and resources, and feedback or input from the family are all of great value when the nurse is prioritizing the client's nursing diagnoses.

Who is considered to be the first nursing researcher?

Florence Nightingale

Who is considered to be the first nursing theorist who conceptualized nursing in terms of manipulating the environment?

Florence Nightingale

A client has presented to the emergency department after splashing a chemical in the eyes. When managing the injury, what should be included in the plan of care?

Flush eyes with water for 10 minutes

A client comes to the emergency department with a productive cough and an elevated temperature. Which type of assessment would the nurse most likely perform on this client?

Focused

Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy?

Focused

A nurse documents the following nursing diagnosis on a client's plan of care: "Fluid Volume Deficit related to gastrointestinal upset from food poisoning as evidenced by vomiting and diarrhea for the past three days, slow skin turgor, and weight loss." The nurse identifies which part of the statement as the etiology?

Gastrointestinal upset from food poisoning

What must the nurse do to identify actual or potential health problems?

Gather data from sources

A nurse is completing a family assessment during a routine home health visit. The parents have a child with special needs, along with six other children, and the older siblings help out with the younger. Which theory would best help the nurse understand this family's functioning?

General Systems Theory

A nursing theorist examines a hospital environment by studying each ward and how it works individually, and then relates this information to the hospital as a whole working entity. This is an example of the use of which theory?

General systems theory

Which theory emphasizes the relationships between the whole and the parts, and describes how parts function and behave?

General systems theory

Which piece of client information is subjective?

Generalized myalgia or muscle pain

The nurse is teaching a client how to take medications upon discharge. The client is alert and oriented but unable to articulate the teaching back to the nurse. What is the appropriate nursing action?

Give written instructions to client and caregivers

A nurse who is preparing to administer an injection to the client states, "This injection will not be painful." The nurse has used which communication technique?

Giving false reassurance

Which may be classified as a nursing diagnosis?

Grieving

The Standards of Practice provide nurses with:

Guidelines for providing care

When educating families on fire safety in the home, which information is important for the nurse to emphasize?

Have a meeting place outside the home in case of a fire

A pregnant client asks the nurse for information on breastfeeding. What type of nursing diagnosis should the nurse formulate?

Health promotion nursing diagnosis

The nurse is caring for an adolescent verbalizing a desire to seek counseling for grief related to the death of a close friend. The nurse determines that an appropriate nursing diagnosis for this client is Readiness for Enhanced Coping. What type of nursing diagnosis is Readiness for Enhanced Coping?

Health promotion nursing diagnosis

After collecting data from a client with respiratory distress, the nurse prioritizes the client interventions to provide oxygen to the client first. This is an example of which model for organizing data?

Hierarchy of Human Needs

A nurse is caring for a toddler who has been treated on two different occasions for lacerations and contusions due to the parents' negligence in providing a safe environment. What is an appropriate nursing diagnosis for this client?

High Risk for Injury related to unsafe home environment

A client recently diagnosed with pancreatic cancer tells the nurse, "I don't see any hope for my future." What would be the most appropriate nursing diagnosis for the nurse to formulate to address this health problem?

Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis

What teaching will the community health nurse include for parents of toddlers?

Household cleaners must be kept out of reach

When developing nursing diagnoses, the nurse should focus on which area?

Human responses to actual or potential health problems

Which best describes the purpose of nursing diagnoses?

Identification of client problems that nurses can treat independently

The purpose of obtaining a nursing history is to:

Identify actual and potential nursing diagnoses

It is important for the nurse to empathize with the client to develop a positive, therapeutic relationship. What is a characteristic of empathy?

Identifying with the client's feelings

A nurse is interviewing a hospitalized client. Which nurse-client positioning facilitates an easy exchange of information?

If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed.

When administering immunizations, the nurse is engaged in:

Illness prevention

Which would be an appropriate nursing diagnosis for a client with cachexia and decreased weight?

Imbalanced Nutrition: Less than Body Requirements

A nurse is interviewing an older adult client who has experienced a drastic weight loss following a cerebrovascular accident (CVA). The client states, "I have trouble getting groceries because I can no longer drive, so I don't have much food in the house." Based on this evidence, what would be the most appropriate nursing diagnosis?

Imbalanced Nutrition: Less than Body Requirements related to difficulty in procuring food

A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain, which is interfering with the client's ability to ambulate. The nurse accurately documents which nursing diagnosis in the client's records?

Impaired Physical Mobility related to pain

Which assessment findings would support the nursing diagnosis of Impaired Skin Integrity? Select all that apply.

Impaired mobility due to recent stroke Unable to turn in bed without assistance Uncontrolled diabetes

Which statement should the nurse include in the education plan regarding safety issues for a group of adult clients?

In most age groups, motor vehicle accidents are major causes of death.

A nurse manager is teaching staff how to use a new piece of hospital equipment. Which educational setting would be most appropriate for this process?

In-service education

A client is being admitted from the emergency room reporting shortness of breath, wheezing, and coughing. What would the nurse formulate as an appropriate nursing diagnosis?

Ineffective Airway Clearance

The nurse is assessing a 3-week-old infant who has not gained weight since birth. The infant's bowel sounds are present in all quadrants and breath sounds are clear to auscultation. The infant's mother reports that the child cries much of the night but sleeps better in the daytime. The mother reports that the child only breastfeeds about four times in a 24-hour period and that the mother doesn't seem to have much milk. Which nursing diagnosis would be of highest priority for this client?

Ineffective Breastfeeding

Which is the best example of a nursing diagnosis?

Ineffective Breastfeeding related to latching as evidenced by nonsustained suckling at the breast.

A client with diabetes mellitus has been admitted to the hospital in diabetic ketoacidosis. During the admission assessment of the client, the nurse learns that the client is not following the prescribed therapeutic regimen. The client states, "I don't really have diabetes. My doctor overreacts." What is the most appropriate diagnosis for this client's health problem?

Ineffective Health Maintenance related to client's denial of illness

A nurse is assessing an adult client's blood pressure. How should the nurse estimate the client's systolic blood pressure (SBP)?

Inflate the blood pressure cuff while palpating the client's brachial artery.

The nurse is preparing a client with a bowel obstruction for emergency surgery. Which intervention has the highest priority for this client?

Inform the client what to expect after the surgery.

For a hospital to meet criteria regarding nursing care established by The Joint Commission, the nurse must conduct which type of assessment?

Initial

The nurse and the physical therapist discuss the therapy schedule and goals for a client on a rehabilitation unit. What type of communication is occurring between the nurse and the therapist?

Interpersonal

A resident of a nursing home keeps trying to get out of bed to use the bathroom, despite having a urinary catheter in place. Which intervention will best preserve this client's safety and could be used as an alternative to restraints?

Investigate the possibility of discontinuing his or her catheter.

Which statement best explains why continuing data collection is important?

It enables the nurse to revise the care plan appropriately

A nurse is assessing a newborn at the health care facility when the mother of the child asks the nurse why the body temperature of her baby is unstable. Which response by the nurse would be most appropriate?

It is because of the immature ability to regulate temperature in general."

A nurse educator is discussing the role of nursing based on the American Nurses Association (ANA). Which statement best describes this role?

It is the role of nursing to provide a caring relationship that facilitates health and healing.

A nurse has been exposed to urine while changing the linens of a client's bed. Which guideline is followed for performing hand hygiene after this client encounter?

Keep hands lower than elbows to allow water to flow toward fingertips.

The nurse is communicating with a client who begins to cry. The nurse places a hand on the client's arm and sits quietly at the client's beside. What mode of communication is the nurse using to offer caring and comfort for the client?

Kinesthetic

A nurse is planning education about prescription medications for a client newly diagnosed with asthma. What nursing diagnosis would be most appropriate for the nurse to select?

Knowledge Deficit: Medications related to new medical diagnosis

A person practicing nursing in the 1950s would most likely have been influenced by what trend?

Large numbers of women began to work outside the home, asserting their independence.

A nurse wishes to pursue a degree as a nurse practitioner. What is the minimal degree needed by the nurse?

Master's

A nurse is reviewing nursing theory for usefulness in a home healthcare setting. Which is the appropriate application of Dorothea Orem's Self-Care Model in a home healthcare setting?

Match the client's self-care needs with appropriate supportive interventions.

The physician has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action?

Medicate the client and wait to ambulate later.

A school nurse is providing information to a group of older adults during Fire Prevention Week. Which statement is correct regarding fires in the home?

Most people who die in a fire die from inhalation and not burns

What best describes the nurse's role in disaster preparedness?

Multiple roles, including triage and the distribution of resources

What association meets every 2 years to further progress in defining, classifying, and describing nursing diagnoses?

NANDA International

The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action?

Notify the physician for additional orders.

The nurse is caring for a postoperative client with confusion, a weak and unsteady gait, and a history of falls. The chart has an order for a waist restraint. What is the nurse's best next action?

Notify the primary care provider and obtain an order for a client sitter.

Which group of nurses would be least likely involved in direct research? Select all that apply.

Novice and student nurses

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?

Nurses do carry out interventions in response to a physician's order.

The role of the nurse developed from the pre-civilization era through the eras representing the beginning of civilization, the beginning of the 16th century, the 18th and 19th centuries, World War II era, and up to the present day. Place the following roles of the nurse listed below in the correct chronologic order to follow this timeline.

Nurses were portrayed as a mother, caring for family and delivering physical care and health remedies. Nurses were viewed as slaves, carrying out menial tasks based on the orders of the priest. There was a shortage of nurses; criminals were recruited as nurses; nursing was viewed as disreputable. Florence Nightingale elevated nursing to a respected occupation and founded modern methods in nursing education. Efforts were made to upgrade nursing education, and women were more assertive and independent. Nursing was broadened in all areas and was practiced in a wide variety of settings; nursing was viewed as a profession.

The formulation of nursing diagnoses is unique to the nursing profession. Which statement accurately represents a characteristic of diagnosing?

Nurses write nursing diagnoses to describe client problems that nurses can treat.

A computerized information system developed to classify client outcomes is the:

Nursing Outcome Classification system

A client is admitted to a hospital unit with scleroderma. The nurse is unfamiliar with this condition. What is the nurse's best source of information about this condition?

Nursing and medical literature

The nurse is assigned a client who had an uneventful colon resection 2 days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change?

Nursing assistant

What is the best explanation for the way evidence-based practice (EBP) has changed the way nursing care is delivered?

Nursing care now uses EBP as a means of ensuring quality care.

A nurse identifies a client's health care needs and devises a plan of care to meet those needs. Which guideline is being followed in this case?

Nursing process

The client's plan of care is created by the nurse using which guideline for nursing practice?

Nursing process

Which represents the basic framework of the research process?

Nursing process

Nurses in an ICU noticed that their clients required fewer interventions for pain when the ICU was quiet. They then asked a researcher to design a study about the effects of noise on the pain levels of hospitalized clients. How does this demonstrate the ultimate goal of expanding the nursing body of knowledge?

Nursing research helps improve ways to promote and maintain health.

Which theory describes, explains, predicts, and controls outcomes in nursing practice?

Nursing theory

A client comes to the emergency department with flulike symptoms. The nurse records the vital signs and listens to the client's lung sounds. Vital signs and lung sounds are examples of which type of data?

Objective

After performing the admission assessment on an older adult client, the nurse documents the following, "Client observed fidgeting with covers; facial grimacing when turning from side to side." This documentation is an example of which type of data?

Objective

The nurse is assessing a client for changes in health condition. After listening to the client's lungs for adventitious breath sounds, the nurse also checks the client's latest white blood cell count. The nurse is gathering which type of data when looking up the lab value?

Objective

Which nursing skill uses all five senses?

Observation

When preparing to use a bottle of sterile saline for a dressing change, the nurse notes that the date it was opened was two days ago. What should the nurse do?

Obtain a new bottle of sterile saline.

A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety?

Obtain a three-prong grounded plug adapter.

What might a nurse need to do to ensure the continuation of his or her nursing license?

Obtain continuing education credits.

The nurse makes a contract with the client during which phase of the nurse-client relationship?

Orientation phase

When caring for a psychiatric client, a nurse would make a formal contract with the client during which phase of the nurse-client relationship?

Orientation phase

A client has been diagnosed with a recent myocardial infarction. What collaborative problem would be the priority for the nurse to address?

PC: Decreased Cardiac Output related to cardiac tissue damage

The nurse is conducting a client interview and notices that the client answers every question with a "yes" or "no" response. What is most likely the cause of this action by the client?

Pain

The focus of nursing is always on which of the four common concepts in nursing theory?

Person

The nurse is caring for a client who has active tuberculosis and is under airborne precautions. The health care provider prescribes a computed tomography (CT) examination of the chest. Which action by the nurse is appropriate?

Place a surgical mask on the client and transport to the CT department at the specified time.

In preparing to administer a drug to a client, the nurse has pierced a multi-use vial of medication. What is the appropriate nursing action?

Place the date on the vial and retain for future use

When the nurse enters the room to assess a client's vital signs, the client insists that the nurse perform handwashing. What is the nurse's most appropriate action?

Praise the client for taking an active role in the client's care.

A novice nurse is using the assessment technique of auscultation. What assessment finding can the nurse obtain with this method?

Presence of peristalsis

A group of nurses is planning to investigate the effectiveness of turning immobilized stroke clients more frequently in order to prevent skin breakdown. The team has begun by formulating a PICO question. Which element will the "O" in the team's PICO question refer to?

Preventing skin breakdown

The nurse is caring for a client who was recently diagnosed with diabetes mellitus. Which action demonstrates that the nurse is using the Basic Needs theory?

Providing foot care for the client

What is the primary role of the nurse in the care of clients who experience domestic violence?

Providing prompt recognition of the potential or actual threat to safety

A nurse is evaluating the outcome of the plan of care after teaching a client how to prepare and administer an insulin pen. Which type of outcome is the nurse addressing?

Psychomotor

A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse?

Pulse is felt with difficulty and disappears with slight pressure.

What type of research study would a hospital conduct to explore clients' and families' perceptions of receiving care?

Qualitative

The nurse researcher would like to gather data about the attitudes of young adults on spirituality and health care. What is the most effective form of research on this topic?

Qualitative research

A nurse researcher is collecting nominal data. What type of research is being conducted?

Quantitative research

A nurse researcher must decide on the method for conducting the research. The researcher that plans to emphasize collection of numerical data and analysis would select which method of research?

Quantitative research

The diploma nurse is considering obtaining a baccalaureate degree. Which degree should the nurse investigate?

RN to BSN

A community group has requested the public health nurse to present a program describing the advised schedule of immunizations for children. To plan for this program, what nursing diagnosis would be most appropriate for the nurse to select?

Readiness for Enhanced Knowledge: Childhood Immunizations

An indwelling urinary catheter has been ordered for a client experiencing urinary retention after surgery. When the nurse enters the room to place the catheter, the client reports voiding in the bathroom. Which is the nurse's most appropriate action?

Reassess whether the client still needs the urinary catheter.

The nurse is assessing the temperature of an 8-month-old infant using a tympanic membrane thermometer. The reading is 95.2°F (35.1°C). What should the nurse do next?

Recheck the temperature, paying close attention to technique

The nurse is reporting to an oncoming nurse about the care of a client using the SBAR format. The nurse informs the oncoming nurse that the client should continue to have neurolgoical checks every 2 hours and the nurse should report any alterations to the health care provider. In which section should this information be relayed?

Recommendation

Which is the best example of evidence-based nursing practice?

Recommending ginger to alleviate nausea and vomiting in obstetric clients based on a literature review

The nurse has received a telephone order for a client from a health care provider. How will the nurse indicate in the documentation that the order was received via telephone?

Record "T.O." at the end of the order.

Which nursing intervention would be most appropriate for a new mother that calls the nursery for help with breastfeeding?

Refer mother for home care visit

The nurse is providing discharge teaching to the family of an older adult client. Which teaching will the nurse include to decrease the risk for electric shock?

Refrain from using extension cords

The nurse is caring for a client who has been placed in strict isolation. Which nursing action is appropriate?

Remove fresh fruit from room

While administering a medication via a syringe, a client sharply moves and the nurse accidentally encounters a needlestick. What is the priority nursing action?

Report needlestick to the nurse manager

A client with hypertension being seen for follow-up care has a blood pressure of 160/100 mm Hg. The client reports following the treatment regimen closely and that blood pressure readings have been elevated for the last 2 weeks. What is the nurse's most appropriate action?

Report the findings to the physician for further plans

Which is a legal responsibility of a nurse who has documented a nursing diagnosis related to a client's kidney failure?

Reporting signs and symptoms related to the client's kidney failure

A nurse is moving to another state and will be working at an acute care facility. Prior to beginning practice, what actions should the nurse take to be compliant with state guidelines for nursing practice? Select all that apply.

Research the laws and regulations that govern nursing practice in the new state Locate the state nursing practice acts Access educational resources related to nursing practice in another state Define the legal requirements and titles for registered nurses (RNs) and licensed practical nurses (LPNs)

A nurse is preparing discharge education for a client with a newborn baby. What is the highest priority item that must be included in the education plan?

Restrain the baby in a car seat

Which error has the nurse made in formulating the following nursing diagnosis: Prolonged Immobility related to impaired skin integrity as evidenced by an open area with a 1-inch diameter on the right buttocks surrounded by a 1-inch margin of redness; wound surface clean and beefy red; no drainage or foul odor detected.

Reversed the health problem and the etiology

What should the nurse do prior to performing an initial assessment on a newly admitted client?

Review records available

A nurse who has been caring for a client for the past few days is preparing the client for discharge and termination of the nurse-client relationship. Which activity would the nurse be carrying out during this phase of the relationship?

Reviewing health changes

A client admitted for a surgical procedure tells the nurse, "I am very worried because I am allergic to latex. I want to make sure that everyone knows this." To ensure the safety of the client, which nursing diagnosis should the nurse assign to this client and address in the care plan?

Risk for Allergy Response related to latex allergy

A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis would the nurse use to address this concern?

Risk for Community Contamination related to possible environmental pollution

Which is an accurately phrased risk nursing diagnosis?

Risk for Falls related to altered mobility

The nurse is caring for a 14-year-old client who has just delivered a baby. The client reports living with an aunt and having no other family around. The delivery was uncomplicated and the newborn is healthy. Which would be the primary nursing diagnosis for this client?

Risk for Impaired Parenting

Which statement appropriately identifies a risk nursing diagnosis for a client who is confined to bed?

Risk for Impaired Skin Integrity related to bed rest

The nurse has completed a comprehensive assessment of a client who has been admitted to the hospital experiencing acute withdrawal from alcohol. What nursing diagnosis would provide the clearest justification for the use of physical restraints during this client's care?

Risk for Injury Related to Agitation

The nurse is caring for a young child in the hospital who is being discharged home with his grandmother, who has guardianship. When performing a risk assessment, the nurse identifies that his grandmother has one other adult living with her to help with the child, because the grandmother has congestive heart failure and diabetes mellitus. In addition, the financial situation is poor and she cannot afford to buy safety devices to safety-proof the house. What nursing diagnosis is most appropriate for this child based on these findings?

Risk for Poisoning related to medications in unlocked cabinets

A nurse is educating a client about care to be taken in nephrotic syndrome. The client expresses that the education is of no use because the disease is not curable. What nursing diagnosis should the nurse formulate with regard to the client's concern?

Risk for Powerlessness

The nurse is assessing a client in an outpatient setting. The client states,"I don't want to live anymore. My family hates me, and I am so tired of being sick. I have a gun, and I am seriously thinking of killing myself." The client reports a 30-year heavy smoking habit and having a cough for about 6 months. Ascultation reveals diminished breath sounds in the right upper lobe. The abdomen is distended with diminshed bowel sounds. The client's lips are slightly bluish in color. Which is the priority nursing diagnosis for this client?

Risk for Suicide

A nurse is discussing dietary issues with a Latino client in the clinic. The client states, "I read a research article about the importance of beans in the Latino diet. The findings from the study suggested that inclusion of meat and beans in the diet would help in the development of muscles and bones." The information that the client is expressing is known as what?

Scientific knowledge

A nurse is planning to participate in a research project and is looking for information about what is already known about the topic. The nurse is involved in which step of the research process?

Scientific literature review

A client comes to a health care facility reporting abdominal pain and vomiting. The client's spouse informs the nurse that the client went out for dinner the previous night. The report that the client went out for dinner the previous night is example of data from which type of source?

Secondary

A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care?

Seek research about the disorder

A client who has been taught to monitor her pulse calls the nurse because she is having difficulty feeling it strongly enough to count. She states that she takes her pulse before taking her cardiac medication. She sits down with her nondominant arm on a firm service, palm up. She uses her three fingers to feel just below the wrist on the side closest to the body. She does not press hard and she has a watch with a second hand to use to count it, but she has a very difficult time feeling it. What does the nurse recognize that she is doing wrong?

She should place her three fingers just below the wrist on the outside of the arm with the palm up.

During the interview component of the health assessment, how does the nurse convey to the client that the information is important?

Sitting at eye level with the client

A nurse is attempting to communicate with a client who speaks a different language and does not understand what is being communicated. Which nursing action would best facilitate the communication process?

Speaking slowly and distinctly, but not loudly

For which client would the use of standard precautions alone be appropriate?

Standard precautions apply to blood and all body fluids, secretions, and excretions except sweat.

The nurse begins a shift and finds that the wrong medication has been administered to a client. After completing a safety event report, what should the nurse do next?

Submit the safety report to the appropriate department within the facility so that it can be reviewed.

The second step in implementation of evidence-based practice includes systematic review. To complete a systematic review of the literature, what must the nurse do?

Summarize findings from multiple studies that are related to a particular nursing practice.

The nurse is teaching the caregiver of an infant about safety. Which teaching will the nurse include?

Supervise your child on the changing table.

The nurse is assessing a client with vascular dementia. As a result of this cognitive deficit, the client is unable to provide many of the data that are required. How should the nurse best proceed with this assessment?

Supplement the client's information by speaking with family or friends.

A client is prescribed an opioid analgesic. The nurse is teaching the client about the need to avoid ingesting alcohol with the drug to prevent an interaction which would potentiate the effects of the analgesic. The nurse is describing which event?

Synergism

Which factor is most important in the development of rapport between nurse and client?

TRUST

A health care provider who just arrived on the unit gives a verbal order to the nurse regarding a nonemergent client situation. What is the nurse's appropriate response?

Tactfully request the provider to input the order into the computerized provider order system.

The community health nurse is preparing a campaign to educate the public about heart health. Which forms of verbal communication would be effective to use in this campaign? Select all that apply.

Television Radio A public speech Brochures

What are the best examples of the role of the nurse as a communicator? Select all that apply.

Telling a client their blood pressure Calling a physician about a client's blood pressure Informing the physical therapist that the client's therapy was discontinued Discussing laboratory values with a client

Which explanation accurately differentiates the role of the registered nurse (RN) from that of the licensed practical/vocational nurse (LPN/LVN)?

The LPN/LVN should work under the supervision of an RN.

The registered nurse communicates with the physical therapist that a client is now on strict bed rest due to bradycardia. Which statement best explains the standard exemplified by the nurse?

The RN coordinates care delivery

The nurse conducts a home safety assessment for a client. Which statement best explains the standard of care being implemented?

The RN promotes a safe environment.

A nurse assesses a client, obtaining the information from a primary source. The nurse has gathered the information from which source?

The client

The nurse is formulating nursing diagnoses pertaining to a client with pancreatic cancer. Which factors should the nurse identify as strengths of the client? Select all that apply.

The client has been accompanied by family members to every appointment. The client states a belief in a reward in heaven after death. The client has demonstrated effective coping skills in the past.

A nurse is providing care for clients in a long-term care facility. What should be the central focus of this care?

The client receiving the care

A nursing diagnosis of "Ineffective Coping" has been chosen for a client after receiving a diagnosis of prostate cancer. What assessments would the nurse consider as evidence for this diagnosis? Select all that apply.

The client reports an inability to get adequate restful sleep. The client has difficulty concentrating on the details of treatment options. The client states, "I can't handle all of this."

A nurse has been caring for a client who had a myocardial infarction 2 days ago. During the morning assessment, the nurse asks the client how the client feels. Which scenario warrants further investigation?

The client stares at the floor and states, "I feel fine."

A client diagnosed with advanced lung cancer has a nursing diagnosis of Ineffective Coping. What assessment data would provide evidence to the nurse for this diagnosis?

The client states, "I am sure the doctors have misdiagnosed me."

The nurse has identified a nursing diagnosis of "Risk for Impaired Parenting" for a client who has recently learned of being pregnant. What assessment data would be appropriate to lead the nurse to select this diagnosis?

The client states, "I do not know how to take care of a baby."

What is the most appropriate outcome for the client who has a nursing diagnosis of "Risk for Injury related to the use of assistive mobility devices in an unfamiliar environment?"

The client will demonstrate safety measures to prevent falls.

Which factor is most likely to contribute to the nurse making a diagnostic error?

The client withholds information during assessment

Which is the primary reason for a nurse collecting data continuously on a client?

The client's health status can change quickly

When the nurse communicates with a newly admitted client, the nurse must pay particular attention to nonverbal behaviors. The nurse considers which characteristic as nonverbal communication?

The client's tone of voice

A nurse caring for a client with a respiratory condition notices the client's breathing pattern is getting more irregular and the rate has greatly increased from 18 to 32 breaths per minute. The nurse notes that this client's vital signs are assessed once every shift, but believes the assessment should be done more frequently. Who is responsible for increasing the frequency of this client's assessments?

The nurse

The nurse is admitting a client to a medical unit. The nurse delegates the measurement of the vital signs to an unlicensed assistive person (UAP) while the nurse collects data. After completing the admission process, the client reports a severe headache, so the nurse reassesses the vital signs and find the client's blood pressure extremely elevated. Whose responsibility is the accuracy of the blood pressure measurement?

The nurse

Which is the best example of a client-centered approach to care?

The nurse asks the client about health goals.

A nurse is beginning the preparatory phase of the nursing interview for a client who fractured the left leg in a fall. Which nursing actions occur in this phase of the nursing interview? Select all that apply.

The nurse ensures that the interview environment is private and comfortable. The nurse arranges the seating in the interview room to facilitate an easy exchange of information. The nurse prepares to meet the client by reading current and past records and reports

Which action by the nurse while interviewing a new client would indicate to the charge nurse the need for further traning?

The nurse introduces onself to the client by pointing to the nurse's name badge.

A nurse is communicating the plan of care for a client who is unconscious. Which nursing actions best facilitate this process? Select all that apply.

The nurse is careful what is said in the client's presence because hearing is the last sense to go. The nurse assumes the client can hear and discusses things that would ordinarily be discussed. The nurse speaks with the client before touching the client.

A nurse is communicating the plan of care to a client who is cognitively impaired. Which nursing actions facilitate this process? Select all that apply.

The nurse maintains eye contact with the client. The nurse shows patience with the client and gives the client time to respond. The nurse keeps communication simple and concrete

The nurses on a busy surgical ward use hand hygiene when caring for postsurgical patients. Which action represents an appropriate use of hand hygiene?

The nurse needs to keep fingernails less than 1/4 in (0.63 cm) long.

A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on nursing practice standards for safety?

The nurse places the client in a private room with monitored negative air pressure.

When reviewing the client's history, the nurse notes that the client's last documented bowel movement was 2 days ago. Before the nurse identifies a diagnosis of "Constipation," what assessment must the nurse make?

The nurse should determine the client's normal bowel elimination pattern.

During morning report, the night nurse tells the day nurse that the client refused to allow the technician to draw blood for laboratory testing. What step would be essential for the day nurse to complete before selecting a nursing diagnosis to address this issue?

The nurse should determine the reason for the client's refusal.

A nurse who is experienced caring only for well babies is assigned to the neonatal intensive care unit (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's most appropriate course of action?

The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client.

Which nursing strategy should the nurse employ to assist a child who has difficulty coordinating inspiration with the use of a handheld inhaler?

The nurse should use a nebulizer to administer the medication.

During a home health care visit, the nurse identifies a nursing diagnosis of Caregiver Role Strain for a parent who is caring for a child dependent on a ventilator. What subjective assessment data would support the nurse's diagnosis?

The parent states, "I cannot allow anyone else to help because they won't do it right."

A nurse is explaining to a nursing student why blood pressure is a frequently used assessment parameter in a wide variety of care settings. What can be inferred from an assessment of a client's blood pressure?

The resistance that the client's heart must overcome when pumping blood

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

The sender and the receiver use one another's reactions to produce further messages.

A dialysis nurse is educating a client on caring for the dialysis access that was inserted into the client's right arm. The nurse assesses the client's fears and concerns related to dialysis, the dialysis access, and care of the access. This information is taught over several sessions during the course of the client's hospitalization. Which phase of the working relationship is best described in this scenario?

The working phase

Which statement best explains the importance of theoretic frameworks?

Theoretic frameworks advance nursing knowledge and practice.

To provide effective nursing care, the nurse should engage in what type of communication with the client and significant others?

Therapeutic communication

A registered nurse wishes to work as a nurse researcher. Which is true regarding nurse researchers?

They are responsible for the continued development and advancement of nursing.

Why are quality-assurance programs important in nursing?

They enable nursing to be accountable for the quality of care.

The registered nurse (RN) working with a licensed practical nurse (LPN) understands which about LPNs?

They must take a licensure exam

A nurse practitioner in private practice with a physician is providing psychiatric care to a client with a history of being abused by a spouse. During the last visit, the client stated an intent to leave the spouse. In the next visit, the nurse practitioner will reassess the client's commitment to this intended change. What type of assessment is the nurse practitioner implementing?

Time-lapse

An older adult client who has been living in an assisted living facility for several months informs a visiting family member that a nurse is coming to do some kind of checkup. Which type of check would be most appropriate for the nurse to perform on this client?

Time-lapsed assessment

For which purposes would observing silence be appropriate? Select all that apply.

To allow the client time to reflect on the client's thoughts To allow the client time to reflect on communication that has occurred To allow the client time to formulate an answer after asking the client a question To allow the client time to compose oneself when the client is upset

When performing an assessment, the nurse should focus most on the developmental stage for which client?

Toddler

Which factor is related to the highest proportion of falls in long-term care settings?

Toiletting

A nurse is discussing dietary issues with a Latino client in the clinic. The client states, "My grandmother always told me that I needed to include beans in my diet so that my muscles would grow." The information that the client is expressing is known as what?

Traditional knowledge

A nurse working in a long-established hospital learned a specific approach to administering intravenous injections from the previous generation of nurses at the hospital. This is an example of which type of knowledge?

Traditional knowledge

A nurse is teaching parents about Internet safety for children. Which actions are recommended guidelines for Internet use? Select all that apply.

Use filtering software to block objectionable information. Investigate any public chat rooms used by the children. Be alert for downloaded files with suffixes that indicate images or pictures.

The nurse is preparing to discuss safety with a group of parents of infants. When planning the program, which topic would be most important to include?

Use of blankets, pillows, and stuffed animals in the crib

The school nurse is educating 7th grade children about safety. Which recommendation is most appropriate for this age group?

Use protective sporting equipment.

The student nurse is having difficulty feeling the pedal pulse of the client with a fractured leg. What should the nurse do next?

Use the Doppler ultrasound device.

A nurse is performing an admission assessment on a client who is scheduled for an elective surgery the next morning. When taking vital signs, the nurse finds that the client's temperature is 39.4°C (103°F). What should be the nurse's priority action?

Verbally report the finding immediately to the client's physician.

The need for university-based nursing education programs was brought to light during which important historical time?

WWII

A nurse is in charge of care for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which guideline is accurate for using transmission-based precautions when caring for this client?

Wear gloves whenever entering the client's room.

A physician tells the nurse that nursing is a discipline, but not a profession. Which criteria should the nurse utilize to demonstrate that nursing is increasingly recognized as a profession? Select all that apply.

Well-defined body of knowledge Code of ethics Ongoing research Sets standards

The RN is working with hospital administrators to transform care at their facility. Which nursing competency will be critical for the nurse to utilize?

Work effectively in interdisciplinary teams

Care provided to a client following surgery and until discharge represents which phase of the nurse-client relationship?

Working phase

Which client would most likely require placement of an implantable port?

a 58-year-old woman with stage 3 breast cancer requiring weekly chemotherapy

The client identifies three strategies for minimizing leakage of an ileostomy bag. This is an example of:

a cognitive outcome

A nurse touches the client's hand while discussing the client's diagnosis. This action is:

a communication channel

It is very important to assess for the quality of someone's respirations as well as describe what is heard with auscultation. Which describes stridor?

a harsh, inspiratory sound that may be compared to crowing

The nurse recognizes that health problems that the nurse can address by independent nursing interventions are called:

actual or potential nursing diagnoses.

An 80-year-old client has a body temperature of 97°F (36°C). Which condition best accounts for this client's temperature reading?

advanced age

A nurse during orientation notices that the preceptor gives all subcutaneous injections on a 45-degree angle. When the new nurse asks the preceptor the rationale for the practice the preceptors states, "This is how I do it, and this is how you will do it." The new nurse recognizes this behavior to be:

aggressive

The nurse is caring for a client with tuberculosis. Which precautions will the nurse select for this client?

airborne

The nurse is caring for an older adult with pulmonary tuberculosis. Which precautions will the nurse begin?

airborne

A nurse is attempting to complete an admission database. While taking the history, the nurse notices the client appears uncomfortable and slightly tachypneic. The nurse should:

allow the client to set the pace.

Carl Rogers (1961) studied the process of therapeutic communication. Through his research, the elements of a "helpful" person were described. They include all of the following except which choice?

analysis

A nurse manager is conducting peer reviews of the staff on the critical care unit. Which person would the nurse manager select to evaluate a registered nurse who is certified in critical care?

another rn with critical care certification

The nurse is preparing to administer a medication that the client takes to treat a cardiac dysrhythmia. Which site should the nurse use to assess pulse in this client?

apical

A nurse is considering relocating to another state to practice nursing. Which is the most appropriate action by the nurse to ensure ability to practice in the new state?

applying for a reciprocal license in the new state

The nurse is caring for a client with a new diagnosis of cancer, and allows the client to verbalize fears relating to how to tell the children. The nurse's intervention reflects which aspect of nursing?

art of nursing

A nurse is on lunch break in the hospital cafeteria and sits at a table near a group of physicians eating their lunch. One of the physicians, who is in charge of the nurse's clients, points at the nurse and states, "That guy needs to get fired." The best response by the nurse would be to:

ask to speak to the physician in private and address the disrespectful remark.

An evening shift nurse is caring for a client scheduled for a colon resection in the morning. The client tells the nurse that the client is afraid of waking up during surgery. The best response by the nurse is to:

ask why the client thinks the client will wake up during surgery.

A client arrives at the emergency department after experiencing several black, tarry stools. The nurse should assess for the cause of the client's complaint by:

asking the client whether the client has recently taken ferrous sulfate (iron) or bismuth subsalicylate.

The nurse is administering an intramuscular injection to a client. Which action made by the nurse could assess whether the needle is in the client's blood vessel or not?

aspirating for blood return

The nurse is attempting to assess a client's radial pulse. The pulse is weak, irregular and unable to be counted. What action would the nurse take next?

assess the apical pulse

The nurse graduated several years ago from a 2-year nursing program at a community college near the home city. Recently, the nurse has considered moving from providing direct client care into an administrative role, but recognizes the need for further education to be considered for such a position. The nurse most likely possesses which nursing qualification?

associate degree

A nurse mentoring second-year nursing students from a community college plans clinical experiences for them. These students will most likely graduate in which time frame?

at the end of the year

An obese client has developed peripheral edema as a consequence of heart failure, making it very difficult for the student nurse to accurately palpate the client's peripheral pulses. How should the nurse proceed with this assessment?

auscultate apical pulse

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

be aware of one's own personality.

A medication order has ac written after the medication dosage. What does ac stand for?

before meals

Which factor is not known to cause false blood pressure readings?

being in a warm environment

During the initial assessment of a newly admitted client, the nurse has clustered data as follows: range of motion with gait, bowel sounds with usual elimination pattern, and chest sounds with respiratory rate. The nurse is most likely organizing assessment data according to:

body systems.

A client with chronic obstructive pulmonary disease has been prescribed a bronchodilator to be administered by small-volume nebulizer. The nurse should ensure that the client:

breathes through his or her mouth until all the medication has been inhaled.

Which peripheral pulse site is generally used in emergency situations?

carotid

Which assessment should be conducted by the nurse before the nurse administers tuberculin intradermal injection?

checking for documented allergies to food or drugs

Which parties are essential for the nurse to include in the implementation of a client's plan of care?

client, family, and physician

During an assessment of a newly admitted client the nurse asks the client many questions. The nurse begins the assessment by asking, "How many times have you been hospitalized this year for your back pain?" This is an example of which type of question?

closed question

Each of the following facilitates a therapeutic nurse-client relationship except:

closed-ended questions.

The nurse is caring for a postoperative client. The health care provider has written a prescription for a pain medication, and the prescription gives a dosage range for the amount the nurse may give depending on the severity of the client's pain. This type of functioning within the health care team is called:

collaborative functioning.

A nurse is asking questions about a client's sexual history. It is important for the nurse to:

collect data in a quiet, private environment.

The nurse is assigned to a client who is newly diagnosed with diabetes. The nurse understands that illness causes feelings of insecurity, which may threaten the client's and family's ability to cope. What action should the nurse take with this client?

comforting the client and client's family

The nurse is planning to do a physical assessment on a newly admitted client. The assessment will be a review of systems. This means the nurse plans to:

complete an exam of all body systems.

One of the primary factors that the nurse considers when setting priorities for the client in the acute care setting after cardiac surgery is the client's:

condition

When the nurse researcher informs the participant that the participant's identity will not be linked with the information that is collected, the researcher is ensuring the participant's:

confidentiality

When a nurse picks up a client's contaminated tissue without gloves and fails to wash the hands sufficiently, the nurse provides for the client's organisms to be spread by which type of transmission?

contact

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse can anticipate that the digoxin will:

decrease the apical pulse.

The nurse is caring for a college student with meningococcal meningitis. Which precautions will the nurse begin?

droplet

A client has smoked most of his life and has labored respirations. He is experiencing:

dyspnea

A nurse is caring for a client admitted to the hospital for dehydration. The physical findings consistent with this diagnosis that the client's general appearance can nonverbally communicate to the nurse include:

easy wrinkling of the skin and sunken eyes.

A nurse is preparing to provide discharge instructions to a postpartum client regarding infant care. Before beginning the education session, the nurse should:

eliminate as many distractions as possible.

The nurse is beginning an assessment on a nonverbal client. The nurse must first:

establish eye contact prior to assessing, touching, and interacting with the client.

Which condition will lead to an increase in cardiac output?

exercise

A person's core body temperature is highest in the early morning and lowest in the late afternoon.

false

A client went missing from a long-term care facility and an emergency code was called. After a search of 1 hour, the client was discovered in a utility room that should have been inaccessible. When responding to this event, staff should:

fill out an incident report, with the goal of preventing a similar event in the future.

One of the primary reasons for conducting nursing research is to:

generate knowledge to guide practice

A unit-based infection control task force was developed in an attempt to reduce catheter-acquired infections. The group consists of 10 team members. During the past three meetings, one person dominated the meeting and did not allow other members ample time to speak. The best way to address the team dysfunction is to:

have group members confront the dominant member to promote the needed team work.

A nurse documents the following nursing diagnosis on a client's plan of care: "Readiness for Enhanced Breast-Feeding." The nurse has identified which type of nursing diagnosis?

health promotion

The primary aim of the Healthy People 2020 initiative is:

health promotion

A child is learning to ride a bicycle. He should be instructed to use which of the following protective devices?

helmet

When developing a nursing diagnosis for a client, which should the nurse do first?

identify significant data

A near miss has taken place on a medical unit in which a client nearly received a unit of packed red blood cells of an incompatible blood type. In the follow up to this event, which action should be prioritized?

identifying systemic factors on the unit that may have contributed to the event

A client reports feeling "different" than earlier in the day. When would the nurse anticipate assessing vital signs?

immediately

The temperature is 102°F (39°C) during a heat wave. The nurse can expect admissions to the emergency room to present with:

increased temperature

During the introductory phase of interviewing a client for the purpose of obtaining information for the nursing history, the nurse should:

inform the client of the maintenance of confidentiality.

A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing:

intervention

The nurse observing an interaction between a mother and daughter appropriately identifies the interaction as which communication zone?

intimate

A nurse is administering an injection to a client at a 15-degree angle. The client has a venous access port. Which injection can be administered at this angle?

intradermal

A nurse is providing care to a 3-year-old child admitted with a diagnosis of infectious diarrhea. The nurse needs to insert an intravenous catheter in order to administer prescribed intravenous fluids. In an attempt to foster communication, the nurse should:

involve the child's stuffed animal in the educational session.

The nurse recognizes that identifying outcomes/goals must include:

involvement of the client and family.

Which topic should a public health nurse emphasize when educating older adults on reducing their risk of poisoning?

keeping medications in clearly labeled containers

What was one barrier to the development of the nursing profession in the United States after the Civil War?

lack of educational standards

A prospective nursing student desires a career that will allow the opportunity to provide client care and to assist professional nurses with routine technical procedures. The prospective student needs to be employed in a full-time position quickly due to economic hardship. What type of nursing program would best suit this student?

licensed or vocational nursing program

A nurse can most accurately assess a client's heart rate and rhythm by which of the following methods?

listen with the stethoscope at the fifth intercostal space left mid-clavicular line

In the role of entrepreneur, the nurse's primary responsibility is:

managing a health-related business.

During a course on terrorism, a group of emergency room nurses learns about terrorists who use bombs or other explosives to inflict injury on numerous people and cause multiple fatalities. This is an example of:

mass trauma terrorism

When communicating with clients, nurses need to be very careful in their approach. This is particularly true when communicating using:

medical terminology

All of the activities listed are related to evaluation, but which activity is the priority concern for nurses?

meeting the care needs of clients

The nurse is caring for a client who became very ill after ingesting seafood. How will the nurse document this condition?

noncommunicable disease

The nurse is caring for a client for the third day in a row on the hospital unit. At the client's evening vital sign assessment, the nurse notices that the radial pulse is much slower than the apical pulse. This finding is new. What should the nurse do next?

notify the physician of the change and document the finding

A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care?

nurse case manager

The nurse is coordinating care for a client with continuous pulse oximetry who requires pharyngeal suctioning. To which staff member should the nurse avoid delegating the task of suctioning?

nursing assistant who is a nursing student

If a nurse describes a study of people and the nursing profession including studies of education, policy development, ethics, and nursing history, then what is the nurse defining?

nursing research

A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on the client's activities of daily living (ADLs) during the period of recovery. When should the nurse begin discharge planning to address this client's ADLs?

on the client's admission to the hospital

The nurse who is caring for a client in contact isolation is preparing to conduct an assessment. Which stethoscope will the nurse choose to auscultate the client's bowel sounds?

one that remains in the client's room

A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based on improvements in the client's condition. This is an example of which type of planning?

ongoing

A home care nurse discusses with a client when visits will occur and how long they will last. In what phase of the nurse-client relationship is this type of agreement established?

orientation

A nurse enters the client's room and states, "Hello, Mr. Alonso. My name is Anthony Bader. I will be your registered nurse today. I will be providing your nursing care and will be with you until 3:30 PM. If you need anything, please call me on my phone or put your light on." The nurse then gives the client a printed card with this information. In the helping relationship, which phase does this represent?

orientation phase

The nurse places a client experiencing labored breathing in an upright position. The nurse notes that the client is able to breathe more easily in this upright position and documents this condition on the chart as:

orthopnea

Which outcome best reflects achievement of the goal, "The client will demonstrate correct steps in taking his own pulse rate"?

palpation of the radial pulse on the thumb side of the inner aspect of the wrist.

Which are core concepts in nursing theory? (Select all that apply.)

person (client), environment, health, nursing

A nurse is caring for a client who sustained head trauma. The client is in a medically induced coma and on mechanical ventilation. The client's mother is at the bedside in tears. The mother states, "I just want him to know I am here with him." To address the needs of the mother and the client, the nurse should:

place a chair next to the bed and encourage the mother to hold the son's hand.

The nurse is caring for a client who has normal saline infusing through a peripheral intravenous catheter with a prescription for a secondary infusion of antibiotic. Which technique would be most appropriate for the nurse to administer the secondary infusion by gravity?

placing the secondary infusion higher than the primary solution

A nurse makes a nursing diagnosis of Constipation after a client reports not defecating on the last trip to the bathroom. The nurse has no other information on the client's defecation history. This is an example of:

premature closure.

When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent?

psychomotor

Which nursing actions will increase efficient management of client care and decrease the ramifications of the nursing shortage? (Select all that apply.)

pursuing postlicensure education becoming cross-trained in another area of the hospital implementing evidenced-based clinical pathways coordinating health care services before client discharge

Which term indicates a potentially serious client condition?

pyrexia - increase above normal in body temperature.

An infection-control nurse is discussing needlestick injuries with a group of newly hired nurses. The infection control nurse informs the group that most needlestick injuries result from:

recapping a needle.

An experienced nurse has been working with a client with heart failure. The client's lungs were clear to auscultation during the morning assessment; however, the afternoon assessment revealed bibasilar crackles and tachypnea. The nurse calls to give SBAR report to the covering health care provider. In the final step of the report the nurse should:

recommend 40 mg of furosemide be administered because the client had improvement with past administration.

The nurse has delegated an unlicensed assistive personnel (UAP) to obtain a temperature reading for a client who has neutropenia. Which route used by the UAP requires immediate intervention?

rectal

A nurse is caring for an adult with fever. The nurse determines that which site is most ideal for obtaining the client's core body temperature?

rectal. The rectal temperature, a core temperature, is considered to be one of the most accurate routes.

A nurse is caring for a client who presents with a skin infection. While obtaining the client's medical history, it is determined that the client is an intravenous drug user. To foster effective communication, the nurse should:

remain honest, open, and frank.

The nurse is taking a rectal temperature on a client who reports feeling lightheaded during the procedure. What would be the nurse's priority action in this situation?

remove thermometer and assess blood pressure and hr

During the preparatory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should:

review as much information as possible

The primary purpose for evaluating data about a client's care according to a functional health approach is to:

revise or modify the client care plan

A nurse is assessing a client's lower arm for insertion of an IV catheter. The nurse palpates the vein and notes that it feels hard. Which action by the nurse would be most appropriate?

select another site

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

sender

A nurse is at the end of a busy shift on a medical-surgical unit. The nurse enters a room to empty the client's urinary catheter and the client says, "I feel like you ignored me today." In response to the statement, the nurse should:

sit at the bedside and allow the client to explain the statement.

The client recently immigrated from Mumbai, India. The client was just admitted to the nurse's unit postoperatively following gallstone removal. The client does not speak the dominant language. When using the hospital's interpretive services, which is most important?

speak directly to the client

The nursing supervisor is evaluating how many clients each of the department nurses has been assigned for the shift. This type of evaluation would be considered:

structure

A client has an inguinal hernia repair and later develops a methicillin-resistant Staphylococcus aureus (MRSA) infection. What is the most important factor to prevent this infection?

surgical asepsis

A nurse is attempting to calm an infant in the nursery. The nurse responds to the highest developed sense by:

swaddling the child and gently stroking its head.

A nurse is preparing to enter a client's room to perform wound care. The shift report revealed that this client has a tunneling wound in the sacral area that cannot be staged. The wound was also documented as having a foul odor. The nurse is nervous because the nurse has not performed wound care on a complex wound in the past. Using effective intrapersonal communication, this nurse should:

tell oneself to "remain calm" and remember that the nurse was trained to perform this skill.

A pulse deficit is the difference between:

the apical pulse and the radial pulse rates.

The nurse is caring for assigned clients who are all stable. Which client should the nurse see first to minimize the spread of infection?

the client who is 48-hours postsurgical procedure

When developing an appropriate nursing diagnosis, the nurse needs to keep in mind that:

the interventions planned must be within the nurse's scope of practice.

What is the purpose of establishing a nursing diagnosis?

to describe a functional health problem

The primary reason for the Controlled Substances Act is:

to prevent drug use and dependence.

During measurement of a rectal temperature, the thermometer probe should be inserted about 1.5 inches (3.8 cm) in an adult and 0.5 inches (1.3 cm) in an infant.

true

A nurse is caring for a 55-year-old postoperative client. The client returns to the ICU after surgery intubated and mechanically ventilated with a Salem sump nasogastric tube, a Foley catheter, and a PICC line in place. Based on the nurse's knowledge of the most common hospital-acquired infections, which apparatus is most important to remove first?

urinary catheter

Evidence-based care emphasizes decision making based on the best available evidence and:

use of outcome studies to guide decisions.

Which error has the nurse made in formulating the nursing diagnosis: Pain related to nurse failing to administer pain med in a timely manner as evidenced by client pain rating of 7 out of 10, client guarding abdominal incision, client ambulating slowly?

used legally inadvisable terms

A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse:

uses broad, open statements to communicate with the client.

A nurse needs to administer a prescribed injection to a toddler. Which injection site is most suitable for the client?

vastus lateralis site

The nurse is preparing to assess the client's vital signs. The client just had their morning coffee. What is the appropriate nursing intervention?

wait 30 mins then assess vital signs

When used in a nursing diagnosis, the descriptor "impaired" has which meaning?

weakened or damaged

A nurse is caring for a client with rubella. Which nursing action is an important precaution to be taken when caring for this client?

wearing a mask when working within 3 feet (1 m) of the client

The nurse is aware that nursing diagnoses are:

within the nursing scope of practice to develop and client-focused.

A 70-year-old client is taking his own pulse at home. He is following the instructions provided by the nurse. He counts his pulse 62 times in one minute. What should he do next?

write it down