Prep U Questions Exam 2

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A client at a health care facility has been diagnosed with polyuria. Which question should the nurse ask the client to determine the cause? A) "Have you ever had an elevated blood sugar?" B) "Is it uncomfortable to urinate?" C) "Have you ever had urinary retention before?" D) "Have you ever had kidney disease?"

A client states to the nurse, "I understand that I need a mastectomy for the treatment of my breast cancer, but I am fearful of learning about the drains I will need to empty." When responding to the client, the nurse will need to address which type of learning? A) Affective B) Behavioral C) Cognitive D) Psychomotor

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? A) Disturbed Body Image related to loss of hair B) Disturbed Body Image as evidenced by client's refusal to look at self C) Disturbed Body Image related to breast cancer D) Disturbed Body Image as evidenced by client's negative comments

A client with anorexia nervosa has developed a pressure injury on the sacrum. Which laboratory result would indicate the client is at nutritional risk? A) Total lymphocyte count of 1,500/mm3 (1.50 x 109/L) B) Body weight decrease of 3% C) Albumin level of 3.5 mg/dL (35 g/L) D) Arm muscle circumference 90% of standard

A client with frequent urinary tract infections (UTIs) has returned to the ambulatory clinic with symptoms of another UTI. Which information is essential for the nurse to review with the client as a strategy to decrease future risk of UTI? A) Voiding before and after sexual intercourse B) Wiping the perineal area from the rectal area to the urethra C) Wearing satin or silk underwear that hugs the skin tightly D) Taking baths instead of showers

A client with lactose intolerance is experiencing abdominal distress, gas, and diarrhea after breakfast each morning. After reviewing the client's food journal, which meal should the nurse point out as a potential trigger? A) Sandwich with deli meat B) Fried eggs and toast C) Fruit and plain bagel D) Peanut butter protein bar and black coffee

A nurse collects a clean-catch specimen from a client at a health care facility. Which statement describes a clean-catch urine sample? A) a sample of urine that is considered sterile B) a sample of urine collected over a period of 24 hours C) a sample of urine collected in a sterile environment D) a sample of fresh urine collected in a clean container

A nurse delegates a specific intervention to an unlicensed assistive personnel (UAP). What implications does this have for the nurse? A) The nurse transfers responsibility but is accountable for the outcome. B) The UAP can function in an independent role for all interventions. C) Nurses do not have authority to delegate interventions. D) The UAP is responsible and accountable for one's own actions.

A nurse documents a client's hemoglobin as 8 g/dL (80 g/L). What nutritional condition does this biochemical data signify? A) Anemia B) Dehydration C) Malabsorption D) Malnutrition

A nurse drafts an SBAR communication before contacting the primary care provider of a client whose condition has worsened suddenly. How should the nurse best conclude this communication? A) Ask the care provider to come and assess the client. B) Provide the client's most recent vital signs. C) Ask whether the care provider is familiar with this client. D) Provide the most likely diagnosis of the problem.

A nurse has developed a plan of care with nursing interventions designed to meet specific client outcomes. The outcomes are not met by the time specified in the plan. What should the nurse do now in terms of evaluation? A) Make recommendations for revising the plan of care. B) State "goal will be met at a later date." C) Continue to follow the written plan of care. D) Ask another health care professional to design a plan of care.

A nurse has just received a client's laboratory results and is reviewing them. Which finding should the nurse recognize as an indication of malnutrition or malabsorption? A) Serum albumin 2.8 g/dL (28 g/L) B) Hematocrit (Hct) 56% (0.56) C) Hemoglobin (Hgb) 11.3 g/dL (113 g/L) D) Creatinine 1.9 mg/dL (168 µmol/L)

A nurse instructs a client to tell the nurse about the side effects of a medication. What learning domain is the nurse evaluating? A) Cognitive B) Affective C) Emotional D) Psychomotor

A nurse is removing the staples from a client's surgical incision, as ordered. After removing the first few staples, the nurse notes that the edges of the wound pull apart as each staple is removed. What is the nurse's best action? A) Stop removing staples and inform the surgeon B) Apply an occlusive pressure dressing after removing the staples. C) Apply adhesive wound closure strips after each staple is removed. D) Stop removing staples and apply an abdominal pad over the incision.

The emergency room (ER) has a strict protocol regarding intramuscular (IM) injection technique. A nurse working in the ER has learned of a new technique to decrease pain with IM injections from the nursing literature and would like to use it. What is the most appropriate way for the nurse to implement the technique? A) Petition to change the protocol based on the new evidence. B) Research the protocols at other area emergency rooms. C) Ask the ER physician to order IM injections with the new technique. D) Begin using the technique to determine whether it is effective.

The nurse is teaching a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include? A) "It provides a way to remove drainage and blood from the surgical wound." B) "You will receive medication through this device." C) "This drain minimizes the chance for bacteria to enter the surgical site." D) "The bulb-like system will stay in place permanently after your mastectomy."

The nurse is using an assessment guide that includes a hierarchy of five life requirements universal to all persons. Which model for organizing assessment data is the nurse using? A) Human Needs (Maslow) model B) Body System model C) Functional Health Patterns model D) Human Response Patterns model

The nurse observes the client for signs of stage I pressure injury development, which most likely will include which finding? A) nonblanchable redness B) a shallow open injury C) visible subcutaneous fat D) exposed bone with eschar

The nurse reports for duty in the emergency department and notes the following clients for which the nurse will be assuming care. After receiving the hand-off report, which client should the nurse prioritize for care? A) 12-year-old female with asthma attack B) 24-year-old female with cough and fever C) 21-year-old male with possible fracture D) 7-year-old male with hand laceration

The primary purpose of nursing implementation is to: A) help the client achieve optimal levels of health. B) implement the critical pathway for the client. C) improve the client's postoperative status. D) identify a need for collaborative consults.

What activity is carried out during the implementing step of the nursing process? A) Planned nursing actions (interventions) are carried out. B) Assessments are made to identify human responses to health problems. C) Mutual goals are established and desired client outcomes are determined. D) Desired outcomes are evaluated and, if necessary, the plan is modified.

Which assessment data cue does the nurse recognize as subjective data? A) A pain rating of 7 B) Wheezing throughout lung fields C) Pupils equal and accommodate and react to light D) Bilateral pedal edema 2+

Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine? A) 24-hour specimen B) random specimen C) intermittent specimen D) clean-catch specimen

Which medication causes constipation? A) Iron supplements B) Magnesium antacids C) Bisacodyl D) Aspirin

Which method of documenting client data is least likely to hold up in court if a case of negligence is brought against a nurse? A) charting by exception B) problem-oriented medical record C) FOCUS charting D) PIE charting system

Which nursing intervention is most likely to be allowed within the parameters of a protocol or standing order? A) Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners B) Administering a beta-adrenergic blocker to a new client whose blood pressure is high on admission assessment C) Changing a client's advance directive after the prognosis has significantly worsened D) Changing a client's intravenous (IV) fluid from normal saline to 5% dextrose

Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? A) Bed bath for the newly admitted client who has multiple skin lesions B) Ambulation of the client with a history of falls for the first time after surgery C) Insertion of a urinary catheter in a client with benign prostatic hypertrophy D) Preparation of insulin for the diabetic client with an elevated blood glucose level

The nurse is performing an admission assessment on a young client admitted to the unit. Which are considered objective data? Select all that apply. A) 38-year-old man B) Height: 6 ft (1.82 m) C) Weight: 195 lb (89 kg) D) "I am afraid something serious is wrong." E) "My leg hurts."

A, B, C

Total parenteral nutrition (TPN) has been ordered for a client. The nurse is aware that the assessment criteria for ordering TPN is what? Select all that apply. A) Renal or hepatic failure B) Client is not able to absorb nutrients properly C) A debilitating condition for more than 2 weeks D) Intact gastrointestinal tract E) Tolerating a full-fluid diet

A, B, C

Which are appropriate actions for protecting clients' identities? Select all that apply. A) Document all personnel who have accessed a client's record. B) Have conversations about clients in private places where they cannot be overheard. C) Place light boxes for examining X-rays with the client's name in private areas. D) Ensure that clients' names on charts are visible to the public. E) Orient computer screens toward the public view.

A, B, C

Which client outcomes are physiologic outcomes? Select all that apply. A) The client's blood pressure is 118/74 mm Hg. B) The client rates pain as a 6. C) The client's hemoglobin A1c level is 7.4%. D) The client describes manifestations of wound infection. E) The client self-administers insulin subcutaneously.

A, B, C

Which examples are essential components for delegating nursing care to an unlicensed assistive personnel (UAP)? Select all that apply. A) The UAP can verbalize what information to report to the nurse. B) The UAP has sufficient knowledge and skill for completing the task. C) The nurse has clearly communicated instructions to the UAP. D) The UAP evaluates the client's response after implementing the task and then reports findings to the nurse. E) The nurse seeks input from the UAP in planning the client's care for the shift.

A, B, C

A client with no significant medical history reports constipation for the past week. Which assessment information will the nurse collect? Select all that apply. A) if the client feels a sensation of rectal fullness B) the client's normal bowel habits C) whether the client is taking new medication D) if the client has used laxatives in the past E) characteristics of loose stools

A, B, C, D

A nurse is assessing the stoma of a client who had an ostomy. Which assessment finding(s) necessitates further evaluation of the stoma? Select all that apply. A) Irritation and dryness at the stoma site B) Bleeding at the stoma site C) Purple-blue color of the stoma D) Pallor of the stoma E) Yellow discharge at the stoma site

A, B, C, D, E

A nurse is giving a verbal report to a health care provider using the ISBAR communication technique. The client being discussed has signs and symptoms of fluid volume deficit. Which statements should the nurse include in the report? Select all that apply. A) "All of the orders have been completed." B) "The client vomited twice and has dry mucous membranes." C) "I am the nurse assigned to the client." D) "The client reports dizziness when walking." E) "I've documented all the care, including the vital signs." F) "Current blood pressure is 90/50 mm Hg with a pulse of 112 bpm."

A, B, C, D, F

Following a client interview, the nurse is organizing data obtained according to Gordon's functional health patterns model. Which statements reflect the focus of this model? Select all that apply. A) The nurse collects data regarding the client's health perception and health management. B) The nurse explores the client's perception of the client's major roles and responsibilities in life. C) The nurse assesses and collects data on the client's elimination, activity, sleep, and sexuality. D) The nurse clusters or organizes data according to a hierarchy of basic human needs. E) The nurse assesses and collects data on the major body systems. F) The nurse collects and organizes data related to human response patterns.

A, B, E

The nurse is providing education for a client with frequent constipation about the use of bisacodyl to improve defecation. What statements made by the client indicate that the teaching is effective? Select all that apply. A) "Bisacodyl will cause irritation of the intestinal mucosa and increase water in the stool." B) "I should increase my fluid intake to help with my bowel movements. C) "This will help add bulk to my stools to ease defecation." D) "This will help soften the stool but won't stimulate motility." E) "It will improve defecation by increasing motility."

A, B, E

The nurse is assessing the wounds of clients. Which clients would the nurse place at risk for delayed wound healing? Select all that apply. A) a client who is obese B) an older adult who is confined to bed C) a 10-year-old client with a surgical incision D) a client who eats a diet high in vitamins A and C E) a client who is taking corticosteroid drugs F) a client with a peripheral vascular disorder

A, B, E, F

A nurse who is planning menus for a client in a long-term care facility takes into consideration the effects of foods and fluids on bowel elimination. Which examples correctly describe these effects? Select all that apply. A) Clients with food intolerances may experience altered bowel elimination. B) A client who is constipated should eat eggs and pasta to relieve the condition. C) Clients who are constipated should eat more fruits and vegetables. D) Clients experiencing flatulence should avoid gas-producing foods such as cauliflower and onions. E) Alcohol and coffee tend to have a constipating effect on clients. F) Clients with lactose intolerance may experience diarrhea or gas when consuming starchy foods.

A, C, D

The following are prescriptions on a client's chart. Which prescriptions would the nurse question because they are written incorrectly? Select all that apply. A) metoprolol 25 mg po daily, hold if BP <100 mm Hg B) 1000 mL NS IV q8h C) heparin 5000U subcutaneously every day D) vancomycin 750 mg IV qod E) lytes in AM F) CXR tonight

A, C, D

A client is receiving total parenteral nutrition (TPN). The nurse will assess for complications related to: A) pain level during infusion. B) fluid and electrolyte levels. C) nausea or vomiting. D) ability to reposition.

A client reads the nutritional chart and follows it accurately. The nurse also notes that the client understands the need for a balanced diet and its relationship with a quick recovery. In which domain is the client demonstrating successful learning? A) Psychomotor B) Cognitive C) Affective D) Interpersonal

A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response? A) "The drain has measurement marks on it so that nurses can measure the amount of drainage and report it the health care provider." B) "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." C) "This drain is called a Jackson-Pratt or bulb drain and is compressed and closed shut to create a gentle suction." D) "The drain works by suctioning out blood and drainage from the wound and will be removed when there is minimal or no drainage."

A client who is bleeding profusely from a stab wound is brought to the emergency department. Which type of assessment is most appropriate for this client? A) Initial B) Emergency C) Focused D) Time-lapse

A client with influenza is prescribed a diet that is rich in fiber and carbohydrates. Which would the nurse incorporate into the education plan as a major reason for the high fiber diet? A) regulation of osmotic pressure in the blood B) maintenance of normal bowel elimination C) promotion of energy storage in adipose tissue D) production of hemoglobin to carry oxygen to tissues

A large university hospital has commissioned a multidisciplinary group to review client records following discharge to evaluate client outcomes and the character and quality of nursing care that clients receive. Which type of evaluation process will take place? A) An accreditation inspection B) A nursing audit C) A process evaluation D) A structure evaluation

A nurse assesses the urine of a client who is using a bedpan and finds that it is a dark brown color. What medication might be causing this effect? A) Diuretics B) Levodopa C) Amitriptyline D) Phenazopyridine

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? A) Slow skin turgor B) Gastrointestinal upset from food poisoning C) Vomiting D) Fluid volume deficit

A nurse is assessing and documenting the eating habits of a client with repeated reports of gas who wants to include more fiber in the diet. Which suggestion should the nurse include in the teaching plan? A) Include more protein in the diet to increase fiber and decrease gas. B) Increase fiber slowly over a period of time to prevent gas. C) Eat more cabbage and brussels sprouts to decrease gas and add fiber. D) Drink a soft drink daily to prevent gas and allow fiber to break down.

A nurse is educating a client on how to administer insulin, with the expected outcome that the client will be able to self-administer the insulin injection. How would the nurse evaluate this outcome? A) Ask the client to verbally repeat the steps of the injection. B) Ask the client to demonstrate self-injection of insulin. C) Ask the client how comfortable the client is with injections. D) Ask family members how much trouble the client is having with injections.

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? A) Affective B) Psychomotor C) Physiologic D) Cognitive

A nurse is initiating a 24-hour urine collection for a client at home. What will be the first thing the nurse will ask the client to do at the beginning of the specimen collection? A) Keep the urine warm during collection. B) Void and discard the urine. C) Add the first voiding to the specimen. D) Begin the collection at a specific time.

A nurse is providing care to several assigned clients and decides to delegate the task of morning vital signs to unlicensed assistive personnel. The nurse would assume responsibility and refrain from delegating this task for which client? A) A middle-aged client who had abdominal surgery 3 days ago and is ambulating in the hall B) A client with a high fever receiving intravenous fluids, antibiotics, and oxygen C) An older adult with pneumonia who is being discharged to the son's home tomorrow D) An adult client who is being treated for kidney stones

A nurse is reviewing the health history and physical assessment findings for a client who is having respiratory problems. Which client statement from the health history would be a cue to a nursing diagnosis for this problem? A) "I just feel so bad about myself these days." B) "I get out of breath when I walk a few steps." C) "I often have diarrhea after I eat spicy foods." D) "My skin is so dry, I just can't keep from scratching."

A nurse is reviewing the plan of care for a client and notes: "The client will verbalize three signs of hypoglycemia to the staff accurately before discharge." The nurse should identify this statement as an example which element of nursing practice? A) Nursing diagnosis B) Outcome C) Intervention D) Evaluation

A nurse uses the SBAR method in a hand-off report to communicate to the health care team about the client. Which element should the nurse cover in the "B" section of the SBAR report? A) Client request B) Mental status C) Vital signs D) Further testing

A nurse will use a bladder scanner to assess a client with urinary frequency. How should the nurse best prepare the client for this procedure? A) Administer a diuretic, as ordered. B) Position the client in a supine position. C) Assess the client's need for analgesia. D) Have the client rest for 15 minutes before the assessment.

The client identifies three strategies for minimizing leakage of an ileostomy bag. This is an example of: A) a physiologic outcome. B) a cognitive outcome. C) an affective outcome. D) a psychomotor outcome.

The focus of a hospital's current quality assurance program is a comparison of the health status of clients on admission and with that at the time of discharge. This form of quality assurance is characteristic of: A) structure evaluation. B) outcome evaluation. C) process evaluation. D) nursing audit.

The nurse caring for a client diagnosed with melanoma has identified a nursing diagnosis of "Ineffective Coping." What subjective assessment data would provide evidence for this nursing diagnosis? A) The client's report of reading the Bible and praying daily B) The client's report of increased consumption of alcohol C) The client's report of eating more fruits and vegetables D) The client's report of researching treatment options for melanoma

The nurse educator is presenting a lecture on clients at risk for developing urinary tract infections (UTIs). Which response made by the staff nurse would indicate to the educator a need for further teaching? A) "Due to the physiologic changes with aging, the elderly are at risk for developing a UTI." B) "Having sexual relationships does not put a woman at risk for developing a UTI." C) "I will make sure to teach my clients with diabetes mellitus to control their glucose level to help prevent a UTI." D) "A woman using an intrauterine device for contraceptive reason is at risk for developing a UTI."

The nurse is calling a health care provider to give an update on a client's condition. The nurse receives a telephone order and, when requests that the order be read back to the provider for confirmation, the provider states, "I don't have time for this." What is the most appropriate action by the nurse? A) Proceed with the order since the nurse heard it the first time B) Inform the provider, to ensure safety for the client, it must be read back C) Ask the secretary to call the provider back and take the order D) Don't follow through with the order, and delete it from the record

The nurse is caring for a client who is postoperative day 2 after a total knee replacement. The client refuses to ambulate when the physiotherapist arrives to the unit. The client states, "It is too soon to get up and walk. I am worried my incision will tear open." The nurse correctly documents the problem-focused nursing diagnosis using which statement? A) Risk for anxiety related to fear of ambulating postoperatively. B) Impaired physical mobility related to anxiety as evidenced by expressed fear of postoperative complications. C) Anxiety related to knowledge deficit regarding normal postoperative activities. D) Risk for postoperative complications due to disturbed body image.

The nurse is caring for a client with frequent urinary tract infections (UTIs). What does the nurse include in the client's teaching plan to decrease the incidence of UTIs? A) Wipe the perineal area from back to front. B) Be sure to urinate after sexual intercourse. C) Try soaking in bubble baths in the evenings. D) Decrease fluid intake to decrease urination.

The nurse is coaching a client who stated a desire to stop smoking without medication. At several sessions to assess the client's success with agreed-upon interventions, the client reports barriers to each action and continues to smoke. What is the best action of the nurse? A) Inform the client that the client will be unable to quit without medication. B) Discuss the client's case with a colleague. C) Inform the client that the results are disappointing. D) Refer the client for cognitive behavioral therapy.

The nurse is performing an assessment on a newly admitted client. The client states, "I feel really nervous." This is an example of which type of data? A) Objective B) Subjective C) Intuition D) Hunch

The nurse is writing client outcomes for a newly admitted client with alcohol withdrawal. Which outcome is the priority? A) Client will commit to completing a 12-step program within 24 hours of admission. B) By day 2 of admission, the client will remain safe and without injury from withdrawal symptoms C) Client will discuss drinking habits in therapy sessions the day after admission. D) Within 3 days, client will be discharged.

The nurse recognizes that identifying outcomes/goals must include: A) involvement of the nurse manager and other staff nurses. B) involvement of the client and family. C) input from the physician. D) input from the multidisciplinary team.

When caring for a client, the nurse observes that the client enjoys reading books and magazines. In which learning domain does the client's learning style fall? A) Affective B) Cognitive C) Psychomotor D) Interpersonal

Which laboratory test is the best indicator of a client in need of TPN? A) Hematocrit B) Serum albumin C) Creatinine D) Hemoglobin

Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy? A) Time-lapse B) Focused C) Initial D) Emergency

When planning care for a client with a Foley catheter, which actions should the nurse include? Select all that apply. A) Change the indwelling catheter regularly. B) Record volume and character of the urine. C) Maintain a closed urinary catheter system. D) Encourage fluid intake, unless contraindicated. E) Use powder or lotion in the perineal area.

B, C, D

A client diagnosed with type 2 diabetes has been prescribed insulin therapy in conjunction with an oral agent because the client has been experiencing difficulty controlling blood sugar levels with an oral agent alone. The nurse is preparing a teaching plan for this client. Which intervention would the nurse include in the teaching plan to address the psychomotor domain? A) Explaining what to do if hypoglycemia occurs B) Describing the signs and symptoms of low blood sugar C) Demonstrating the technique for insulin self-injection D) Reviewing with the client appropriate foods to eat

A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital signs. Which data collected can be classified as subjective data? A) Respiratory rate B) Blood pressure C) Nausea D) Heart rate

A client is brought to the emergency department in an unconscious condition. The client's spouse hands over the previous medical files and points out that the client suddenly fell unconscious after trying to get out of bed. Which is a primary source of information in this case? A) The client's assessment data B) The client's medical documents C) The client's spouse D) The client's test results

A client reports to the nurse quitting smoking 6 months ago after being diagnosed with lung cancer. The nurse recognizes this change in behavior is which type of outcome? A) Cognitive B) Physiologic C) Affective D) Psychomotor

A client states, "I understand when the nurse explains the possible complications of my illness. I am appreciative of what insulin does to my body, and I can now give myself insulin." Which domains of learning does the nurse identify for this client as having been successfully addressed by education? A) Cognitive, pedagogical, and psychomotor B) Gerogogical, andragogical, and pedagogical C) Cognitive, affective, and psychomotor D) Gerogogical, cognitive, and andragogical

A client who has been on a medication that caused diarrhea is now off the medication. What could the nurse suggest to promote the return of normal flora? A) stool-softening laxatives, such as docusate B) increasing fluid intake to 3,000 mL/day C) eating fermented products, such as yogurt D) drinking fluids with a high sugar content

A client who visits a health care facility for a routine assessment reports to the nurse being unable to control urinary elimination. This has resulted in the client soiling clothes and has led to a lot of embarrassment. Which nursing intervention will be appropriate to use with this client? A) Fluid restriction B) Indwelling catheterization C) Regular toileting routine D) Encouraging the client to stay close to home

A female client is diagnosed with a urinary tract infection (UTI) and states this is her second one in the last 6 months. In teaching the client about health promotion, the nurse would include which statement? A) "Routine tub baths are fine as long as you are bathing appropriately." B) "Clean the perineal area from back to front when using the bathroom." C) "Try to urinate immediately after sexual intercourse." D) "Fluid intake is not a factor with urinary tract infections."

A nurse identifies the following nursing diagnosis for a client with an infected leg ulcer: "Deficient Knowledge related to diminished peripheral circulation and wound care as evidenced by recurrent infected leg ulcer." Which statement would the nurse identify as addressing a cognitive outcome? A) "Client chooses correct size of dressing to cover the wound." B) "Client verbalizes being motivated to continue follow-up to prevent recurrence." C) "The client states the reason for wound care measures." D) "The client demonstrates how to irrigate leg wound."

A nurse is admitting a client to a long-term care facility. What should the nurse plan to use to assess the client for risk of pressure injury development? A) Morse scale B) FLACC scale C) Braden scale D) Glasgow scale

A nurse is changing a sterile pressure injury dressing based on an established protocol. What does this mean? A) The nurse is using critical thinking to implement the dressing change. B) The client has specified how the dressing should be changed. C) Written plans are developed that specify nursing activities for this skill. D) The physician verbally requested specific steps of the dressing change.

A nurse is educating a client with a new diagnosis of diabetes. Which example demonstrates cognitive learning by the client? A) The client expresses a desire to improve nutritional intake and lose weight. B) The client prepares the skin for the administration of an insulin injection. C) The client describes signs and symptoms of hypoglycemia. D) The client demonstrates proper technique for injecting insulin.

A nurse is educating a home care client on how to administer a topical medication. The client is watching television while the nurse is talking. What might be the result of this interaction? A) The communication will be reciprocal. B) The receiver will accurately interpret the message. C) The message will likely be misunderstood. D) The stimulus for communication is unclear.

A nurse is evaluating a client's laboratory data. Which laboratory findings should the nurse recognize as increasing a client's risk for pressure injury development? A) White blood cell count 14,800 mm3 (14.8 x 109/L) B) Blood urea nitrogen (BUN) 7 mg/dL (2.50 mmol/L) C) Albumin 2.8 mg/dL (28.0 g/L) D) Hemoglobin A1C 5%

A nurse is providing care to a client who has undergone a colonoscopy. What would be most appropriate for the nurse to do after the procedure? A) Administer a laxative to the client. B) Limit oral fluid intake. C) Monitor for rectal bleeding. D) Avoid giving solid food.

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? A) Consult with another nurse. B) Set priorities using client care standards. C) Seek research about the disorder. D) Follow institutional guidelines.

A nurse manager is discussing a nurse's social media post about an interesting client situation. The nurse states, "I didn't violate client privacy because I didn't use the client's name." What response by the nurse manager is most appropriate? A) "The information being posted on social media is inappropriate. Make sure to discuss information about clients privately with friends and family." B) "All aspects of clinical practice are confidential and should not be discussed." C) "Any information that can identify a person is considered a breach of client privacy." D) "You may continue to post about a client, as long as you do not use the client's name."

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? A) The nurse should recognize the necessity of the assignment and provide care to the best of the nurse's ability. B) The nurse should ask another nurse who was previously assigned to the client for instruction. C) The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client. D) The nurse should request that the blood transfusions be delayed until the next shift.

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: A) provide detailed findings of the head-to-toe assessment. B) detail the client's past medical history and active medication orders. C) recommend 40 mg of furosemide be administered because the client had improvement with past administration. D) discuss the client's situation and request a chest x-ray to assess lung function.

The charge nurse overhears two nurses talking about nursing interventions. Which statement by one of the nurses indicates that further education is required? A) "Nursing interventions must be culturally sensitive and individualized for the client." B) "Nursing interventions must be consistent with standards of care and research findings." C) "Nursing interventions must be approved by other members of the health care team." D) "Nursing interventions must be compatible with other therapies planned for the client."

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? A) Hopelessness related to inability to decide a course of action as evidenced by the client's statement B) Ineffective Coping related to rape trauma syndrome as evidenced by client's inability to make a decision C) Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement D) Complicated Grieving related to mental trauma as evidenced by the client's inability to make a decision

The health care provider is in a hurry to leave the unit and tells the nurse to give morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate? A) Call the pharmacy to have the order entered in the electronic record. B) Add the new order to the medication administration record. C) Inform the health care provider that a written order is needed. D) Write the order in the client's record.

The nurse enters a client's room and observes that the client is hunched over and appears to be breathing rapidly. What type of question should the nurse first ask the client in this interaction? A) A reflective question B) A directing question C) A yes or no question D) An open-ended question

The nurse has formulated the nursing diagnosis: Acute Confusion related to low serum sodium levels as evidenced by sodium 125 mEq/L for a client. What part of the nursing diagnosis is "low serum sodium levels"? A) Client need B) Problem C) Etiology D) Defining characteristics

The nurse is administering magnesium citrate to a client with constipation. What mechanism of action would the nurse expect from this drug? A) Softening of the fecal material B) Chemical stimulation of peristalsis C) Drawing water into the intestines to stimulate peristalsis D) Increasing intestinal bulk to enhance mechanical stimulation of the intestine

The nurse is caring for a client who is being treated following a drug overdose. The client states, "My life is over, I cannot stop using heroin." Which statement would the nurse employ to strengthen the nurse-client relationship? A) "I understand why you feel this way, it is difficult to kick an addiction." B) "Would you like to discuss how long you have been using drugs?" C) "Perhaps we can talk about your feelings some more." D) "Have you reflected on what causes you to use heroine?"

The nurse is reviewing a client's most recent laboratory results, which reveal increases in hematocrit, creatinine, and blood urea nitrogen (BUN). After collaborating with the interdisciplinary team, what intervention is most appropriate? A) Administer a high-protein diet. B) Arrange for total parenteral nutrition (TPN). C) Increase the client's fluid intake. D) Place the client on calorie restriction.

The nurse mentor is observing a novice nurse preparing to insert an indwelling catheter for a female client with urinary retention. The mentor would intervene if which action by the novice nurse is noted? A) The novice nurse assists the client to a dorsal recumbent position with knees flexed, feet about 2 ft (0.6 m) apart. B) The novice nurse asks the client to take a deep breath when resistance was met during insertion of the catheter. C) The novice nurse selects an 18 French Foley catheter to insert. D) The novice nurse places a trash receptacle within easy reach.

What is evaluated when conducting a nursing audit? A) Physical environment B) Client satisfaction C) Client records D) Policies and procedures

What is the best way for the nurse to ensure there is not any tension on the tubing when caring for a client with a Jackson-Pratt drain? A) Apply an abdominal binder over the entire wound and drain to support the site. B) Allowed the Jackson-Pratt drain to hang freely to avoid any kinks in the tubing. C) Secure the drain to the client's gown with a safety pin below the level of the wound. D) Tape the drain to the dressing material securely below the level of the wound.

What is the route of administration for TPN? A) Oral B) Intramuscular C) Intravenous D) Subcutaneous

When documenting client care, the nurse understands that the most important reason for correct and accurate documentation is: A) assisting in organization of care. B) noting the client's response to interventions. C) conveying information. D) reducing legal liability risks.

Which encounter represents nursing negligence? A) Forgetting to document administration of a medication. B) Failing to inquire about the client's advanced directives during the admission process. C) Administering a new antibiotic without subsequently reassessing the client. D) Asking unlicensed assistive personnel (UAP) to complete discharge plan education.

Which example may illustrate a breach of confidentiality and security of client information? A) The nurse provides information to a professional caregiver involved in the care of the client. B) The nurse accesses client information on the computer at the nurses' station, then logs off before answering a client's call bell. C) The nurse provides information over the phone to the client's family member who lives in a neighboring state. D) The nurse informs a colleague that she should not be discussing client information in the hospital cafeteria.

The nurse is caring for a client who does not speak the same language. The unlicensed assistive personnel (UAP) speaks the same language as the client. What parts of communicating with the client could the nurse appropriately delegate to the UAP? Select all that apply. A) Interview the client as part of the admission assessment. B) Provide education to the client, including discharge instructions. C) Orient the client and family to the room, including the call light button. D) Ask the client questions regarding personal care needs. E) Demonstrate and teach new caregiving procedures to the family. F) Counsel the client about making adjustments to a new medical condition.

C, D

What is a violation(s) of the nurse's responsibility when using electronic communication? Select all that apply. A) When a visitor inquired about a hospitalized client, the nurse, prior to answering, closed the computer monitor screen that was open to client data and could be seen by the visitor. B) The nurse wrote on a social media site, "Had a bad day at work. Need some support. Call me." C) The nurse posted on a social media site, "Psychotic mean client in Room 502 hit me," and, within 5 minutes, deleted the post. D) The nurse accidentally texted a message about a new prescription for HIV medications to the wrong phone number. E) The nurse sent an email message to a client informing the client how to access a secured website to view the lab report.

C, D

The nurse is using the ISBARR format to report a surgical client's deteriorating condition to a health care provider. Which actions would the nurse perform when using this guide? Select all that apply. A) The nurse asks the health care provider to describe the admitting diagnosis of the client. B) The nurse asks the health care provider to estimate the discharge date for the client. C) The nurse reads back the physician's new orders at the conclusion of the call. D) After introductions, the nurse states the client name, room number, and problem. E) The nurse states that the client's condition "could be life-threatening." F) The nurse asks the health care provider to comment on the present situation before giving recommendations.

C, D, E

A client at a health care facility has been diagnosed with polyuria. How would the nurse describe the client's condition in the medical record? A) inadequate elimination of urine B) difficult or uncomfortable voiding C) absence of urine D) greater than normal urinary volume

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? A) Head-to-toe B) Time-lapse C) Emergency D) Focused

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? A) Intuitive B) Hunches C) Subjective D) Objective

A client has been admitted to the acute care unit after surgery to debride an infected skin injury. The surgeon reports plans to leave the wound open to promote drainage and later close it. This represents what type of wound healing? A) primary intention B) secondary intention C) quadratic intention D) tertiary intention

A client is prescribed a diuretic for swelling of the lower extremities. What would the nurse teach the client about the effect of the medication on the client's urinary output? A) The client's urine will have a strong ammonia odor. B) The client's urine will be a medium-amber color. C) The client's urinary output will be decreased. D) The client's urinary output will be increased.

A client tells the nurse that he takes laxatives every day but is still constipated. The nurse's response is based on which reasoning? A) If laxatives are not effective, the client should begin to use enemas. B) A laxative that works by a different method should be used. C) Chronic constipation is nothing to be concerned about. D) Habitual laxative use is the most common cause of chronic constipation.

A client with a urinary tract infection is to be discharged from the health care facility. After teaching the client about measures to prevent urinary tract infections, the nurse determines that the education was successful when the client makes which statement? A) "I need to wear pants that are snug fitting to prevent microorganisms from entering." B) "I should wipe from my anus to my vagina after going to the bathroom." C) "I should take frequent bubble baths to make sure my genitalia are kept clean." D) "I need to void after sexual intercourse to flush microorganisms away from my urethra."

A client with chronic kidney disease reports not being able to urinate for the past 24 hours. A bladder scan shows no urine in the bladder. How does the nurse document this data? A) oliguria B) nocturia C) urinary retention D) anuria

A client's recent diagnosis of colorectal cancer has required a hemicolectomy (removal of part of the bowel) and the creation of a colostomy. The nurse would recognize that the client's stoma is healthy when it appears what color? A) dark or purple-blue. B) red and dry C) off-white or pale pink. D) dark pink and moist

A nurse has just taken vital signs on a newly admitted client. Vital signs would be entered on the client record as which type of data? A) Intuitive B) Subjective C) Hunches D) Objective

A physician orders nutritional therapy administered via a central vein for a client who cannot take foods orally. What is the term for this type of nutrition? A) Percutaneous endoscopic jejunostomy tube (PEJ) B) Partial or peripheral parenteral nutrition (PPN) C) Percutaneous endoscopic gastrostomy tube (PEG) D) Total parenteral nutrition (TPN)

During data collection, the client expresses concern over a change in the color of the urine from tea-colored to green since beginning a new medication. Which appropriate question would the nurse ask this client? A) "Are you taking a diuretic?" B) "Are you taking phenazopyridine?" C) "Are you taking levodopa?" D) "Are you taking any B-complex vitamins?"

In which situation would the SBAR technique of communication be most appropriate? A) A nurse is facilitating a family meeting to coordinate a client's discharge planning. B) A nurse is teaching a client about the benefits of smoking cessation and the risks of continuing to smoke. C) A nurse is explaining the process of bone marrow biopsy to a client who is scheduled for the procedure. D) A nurse is calling a physician to report a client's new onset of chest pain.

Prior to the first visit following gastrectomy, the client will have a weight loss of 10 lb (4.5 kg). This is an example of which type of evaluative statement? A) Psychomotor B) Affective C) Cognitive D) Physical changes

The client is being seen for chest congestion, coughing up thick secretions, and shortness of breath for several days and is diagnosed with pneumonia. The client has a two-pack-per-day smoking habit. When developing the plan of care, what would be a priority nursing diagnosis for this client? A) Ineffective Breathing Pattern related to client report of shortness of breath B) Ineffective Therapeutic Regimen Management due to smoking C) Ineffective Health Maintenance as evidenced by smoking and unhealthy dietary habits D) Ineffective Airway Clearance related to tracheobronchial secretions as evidenced by expectorating thick, yellow secretions

The nurse cares for a client with a chronic neurologic condition that decreases the peristalsis. What nursing diagnosis is the most likely risk for this client? A) Deficient Fluid Volume B) Diarrhea C) Excessive Fluid Volume D) Constipation

The nurse enters a client's room to find the client diaphoretic (sweat-covered) and shivering and infers that the client has a fever. How should the nurse best follow up this cue and inference? A) Obtain an order for blood cultures. B) Ask a colleague for assistance. C) Give the client a clean gown and warm blankets. D) Measure the client's oral temperature.

The nurse is caring for a client who is suspected of having a kidney infection. Which scenario involves the use of subjective data from the primary source? A) The physician prescribes medication to help the client void. B) The client's spouse reports the client experienced incontinence a few days ago. C) The nurse tells the client to attempt to void. D) The client tells the nurse that there is a burning sensation when voiding.

The nurse is developing goals for a newly admitted client with visual and auditory hallucinations. Which outcome is the priority for the client? A) Within 2 days, client will perform personal hygiene without reminders. B) Client will understand that the hallucinations aren't real in therapy sessions before discharge. C) Client will verbalize side effects of antipsychotic medications within 24 hours. D) Within 3 days, client will have an interaction with one other client in the day room without disruptive behavior.

The nurse should utilize ISBARR communication (Introduction, Situation, Background, Assessment, Recommendation, Read Back) during which clinical situation? A) When reporting to a client's family member or significant other B) When documenting the care that was provided to a client whose condition recently deteriorated C) When preparing to discharge the client home D) When transferring a client from the emergency department to the acute care unit

What common problem is related to outcome identification and planning? A) Writing nursing orders that are clear and resolve the problem B) Collecting insufficient data to establish a database C) Stating specific and measurable outcomes based on nursing diagnoses D) Failing to involve the client in the planning process

What should the nurse do to make outcomes more achievable? A) Determine which outcomes are most important without any input. B) Simplify outcomes and discourage any changes to them. C) Determine which client outcomes will meet the nurse's goals. D) Encourage the client and family to be involved in the development of outcomes.

When reviewing data collection on a client with constipation, which factor identified by the nurse might suggest the causative factor? A) The client drinks 8 glasses of fluid daily. B) The client eats five to six small meals per day. C) The client traveled to South America two weeks ago. D) The client takes bisacodyl every day.

When should the nurse initiate discharge planning for a client in an acute health care setting? A) Before admission B) After discharge C) At discharge D) At admission

Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury? A) improving the client's hydration B) pulling the client up from under the arms C) lubricating the area with skin oil D) preventing the client from sliding in bed

Which are subjective client data gathered during assessment? A) Pale skin, thick toenails B) Vomiting, pulse rate of 96 beats/min C) Respiratory rate of 22 breaths/min, blood pressure of 130/80 mm Hg D) Nausea, abdominal pain

Which is an example of objective data? A) A client with inner ear infections reports dizziness. B) A client reports feeling very anxious about tests the client is undergoing. C) A client receiving chemotherapy reports nausea. D) The skin of a client who has liver failure has a yellowish tint.

Which is the best example of a nursing diagnosis? A) Ineffective Airway Clearance as evidenced by client not speaking. B) Cellulitis related to infection as evidenced by warm, reddened skin. C) Gastroesophageal Reflux related to low stomach pH as evidenced by foul breath and burning sensation in throat. D) Ineffective Breastfeeding related to latching as evidenced by nonsustained suckling at the breast.

The health care provider has ordered a 24-hour urine specimen collection for a client. Which nursing action is appropriate? Select all that apply. A) Place urine in staff refrigerator. B) Teach client to void only one time per hour. C) Have client label own urine collection. D) Ask client to void for the last time at exactly the 24-hour mark. E) Discard first urine just before starting the test, then collect urine thereafter.

D, E

A nurse has just removed an indwelling catheter from a client. Which common complications of urinary function should the nurse monitor for in the client, after removal of an indwelling catheter? Select all that apply. A) Urinary incontinence B) Increased volume of urine output C) Urinary frequency D) Burning or irritation while voiding E) Difficulty voiding F) Urinary retention

D, E, F

When performing an assessment on an older adult client, the nurse discovers that the client needs a cane when walking and has problems seeing in the night. Under which stage of Maslow's Hierarchy of Needs Theory should the nurse cluster this data? A) Love and belonging B) Self-actualization C) Self-esteem D) Physiologic E) Safety and security

The student nurse studying bowel elimination learns that which statements accurately describe the process of peristalsis? Select all that apply. A) Mass peristalsis often occurs after food has been ingested. B) The sympathetic nervous system stimulates movement. C) Mass peristaltic sweeps occur 1 to 4 times each 24-hour period in most people. D) The autonomic nervous system innervates the muscles of the colon. E) Peristalsis occurs every 3 to 12 minutes.

A, C, D, E

A female client is diagnosed with recurrent urinary tract infections (UTIs) and the nurse is providing education about preventative methods. What information is important for the nurse to give to the client to prevent another UTI? Select all that apply. A) Drink two 8-oz glasses (480 mL) of water before and after sexual intercourse and void immediately after intercourse. B) Take baths instead of showers. C) Dry the perineal area after urination or defecation from the back to the front. D) Wear underwear with a cotton crotch. E) Avoid clothing that is tight and restrictive on the lower half of the body.

A, D, E

A nurse is performing an assessment on a client. Which should the nurse record as subjective data? Select all that apply. A) "My leg hurts when I move." B) Blood pressure: 120/78 mm Hg C) Weight: 132 lb (60 kg) D) "I am always anxious." E) "I am so afraid of what my diagnosis is."

A, D, E

The nurse is preparing to evaluate the goals set for a newborn and mother. What physiologic goals will the nurse evaluate for effectiveness? Select all that apply. A) Before discharge, the baby with a birth weight of 7 lb, 6 oz (3.3 kg) will have reached a target weight of 8 lb (3.6 kg). B) By 4/6/20, the parents will list appropriate resources in case questions arise after discharge. C) Before discharge, the parents of the baby will verbalize decreased anxiety about taking care of a newborn. D) By 4/6/20, the mother will demonstrate a pain rating of 0 on a 0 to 10 scale. E) By 4/6/20, the newborn will demonstrate 2 hours of sleep prior to breastfeeding at night. F) Before discharge, the parents will demonstrate confidence in bathing and feeding their baby.

A, D, E

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate? A) "Your wound will heal slowly as granulation tissue forms and fills the wound." B) "As soon as the infection clears, your surgeon will staple the wound closed." C) "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." D) "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention."

The nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. The client refuses by saying, "I have smoked since I was 12 years old. I am not going to stop now." What is the appropriate response by the nurse? A) "Please tell me your thoughts about treating this diagnosis." B) "What are your plans after discharge?" C) "You need to stop smoking for us to effectively combat this disease." D) "Do you want to be discharged without treatment?"

The nurse has engaged the services of an interpreter when interviewing a client who speaks a language that the nurse does not understand. The interpreter is functioning in which role during the communication process? A) Communication channel B) Sender C) Receiver D) Encoder

The nurse hears an unlicensed assistive personnel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action? A) Remind the UAP about the client's right to privacy. B) Report the UAP to the nurse manager. C) Notify the client relations department about the breach of privacy. D) Document the UAP's conversation.

The nurse is providing in-home care for a client recently prescribed antihypertensive medication. Upon evaluation the nurse obtains a blood pressure reading of 92/58 mm Hg and alerts the provider. In which manner will the nurse execute verbal orders from provider? A) The nurse can accept verbal orders to provide immediate care and record once the client is stable. B) The nurse can implement care once written orders are received from the provider. C) The provider can input orders remotely into the EHR system for the nurse to retrieve. D) The client must be stabilized before the nurse can obtain any orders from the provider.

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 neurological checks every 2 hours and the nurse should report any alterations to the health care provider. In which section should this information be relayed? A) Recommendation B) Situation C) Background D) Assessment

The nurse is reviewing a client's laboratory report. The report indicates the client's albumin level is 2.89 g/L (4.19 mmol/L). Which inference can the nurse make about the laboratory result? A) The client has malnutrition B) The client has been taking steroids. C) The client has an infection. D) The client has likely been on a high protein diet.

Which is a common error nurses make when writing client outcomes? A) Expressing the client outcome as a nursing intervention B) Making the outcome measurable and including actions that are observable C) Including a target time by which the client is expected to achieve the outcome D) Including a subject, verb, conditions, performance criteria, and target time

Which is an accurately phrased risk nursing diagnosis? A) Risk for Falls related to altered mobility B) Risk for Pain After Surgery C) Risk for Fluid Volume Excess related to increased oral intake as evidenced by consuming 3 L of soda D) Risk for Impaired Coping as evidenced by client crying

While assisting a client with a delivery, a nurse takes a photo of the newborn and posts it on a social media website. What action may occur related to this privacy violation? A) The nurse could be fined or even go to jail for violating HIPAA. B) The nurse could be fired but would not face criminal charges or jail time. C) No action will be taken as long as the parents don't find out. D) There will be no repercussions if the nurse takes the photo down from the social media page.

A 24-year-old client presents to the emergency department with signs and symptoms of a sickle cell crisis. The nurse quickly obtains the necessary laboratory tests to assist with the assessment, as well as conducts an assessment of the client to determine the proper nursing care the client will require. Which type of assessment did the nurse perform in this situation? A) Comprehensive B) Emergency C) Initial D) Focused

A client's risk for the development of a pressure injury is most likely due to which lab result? A) sodium 135 mEq/L B) albumin 2.5 mg/dL C) glucose 110 mg/dL D) hemoglobin A1C 7%

The nurse examines the client's lab results: transferrin 220 mg/dL, hemoglobin 33%, serum creatinine 1 mg/dL, BUN 17 mg/dL. The nurse should provide which action? A) Assess urine output. B) Increase foods rich in iron. C) Increase oral intake. D) Decrease proteins in diet.

The nurse has identified the following outcome for the client: The client will have a soft, formed stool. Which error has the nurse made in writing the outcome? A) The nurse has omitted the defining characteristics. B) The nurse has omitted the time frame. C) The nurse has not made any error in writing the outcome. D) The outcome should indicate what the nurse will do.

The nurse in an outpatient provider's office is caring for a client with persistent flatus. Which client teaching will the nurse provide as to why some foods cause flatus? A) "Flatus is a natural action and the cause is unknown." B) "Certain vegetables can cause flatus, as they are more difficult to digest." C) "Drinking alcoholic beverages can cause flatus." D) "Parasites in your stool can cause persistent flatus."

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing: A) initial planning. B) discharge planning. C) comprehensive planning. D) ongoing planning.

The client reports taking bisacodyl daily for several weeks and remains constipated. What are appropriate actions of the nurse? Select all that apply. A) Instruct the client to continue taking bisacodyl until the medication produces a bowel movement. B) Assess the client's diet and fluid intake. C) Ask the client about abdominal pain. D) Auscultate the abdomen for bowel sounds. E) Tell the client to increase fiber intake and keep fluid intake the same. F) Question the client about the color, consistency, pattern, and shape of stools.

B, C, D, F

The student nurse is preparing a presentation on bowel elimination. Which would be a potential cause of diarrhea that the student should include? Select all that apply. A) opioids B) acute stress C) increased physical activity D) antibiotics E) depression

B, D

Which activities take place during the working phase of the nurse-client relationship? Select all that apply. A) The client identifies the goals accomplished in the relationship. B) The client genuinely expresses concerns to the nurse. C) The client and nurse identify goals of the relationship. D) The client participates actively in the relationship. E) The client describes the role that the nurse plays in the relationship.

B, D

A nurse is caring for a client who has recently undergone repair of a ventral hernia. What situations should the nurse assess for that may increase the risk for delay in surgical wound healing? Select all that apply. A) compromised peripheral circulation B) distention of the abdomen from accumulated intestinal gas C) serous fluid accumulation preventing skin tissue approximation D) insufficient protein and vitamin C intake E) weak tissue and muscular support due to obesity

B, D, E

The nurse assesses the stool of clients admitted to the hospital with abdominal distress. Which statements accurately describe the normal characteristics of stool and special considerations for observation? Select all that apply. A) The absence of bile may cause the stool to appear black. B) The rapid rate of peristalsis in the breastfed infant causes the stool to be yellow. C) Consistently large diarrheal stools suggest a disorder of the left colon or rectum. D) Antacids in the diet cause the stool to be whitish. E) The odor of the stool is influenced by its pH value, which normally is slightly acidic. F) A gastrointestinal obstruction may result in a narrow, pencil-shaped stool.

B, D, F

Which are psychomotor outcomes? Select all that apply. A) The client will report increased confidence in testing blood glucose level. B) The client will safely ambulate using a walker. C) The client will rate pain as a 2 on a 0 to 10 pain rating scale. D) The client will identify signs and symptoms of infection. E) Accurately drawing up insulin

B, E

A client age 61 years has been admitted to a medical unit with a diagnosis of pancreatitis secondary to alcohol use. Which statement by the client suggests that the nurse's teaching has resulted in affective learning? A) "I can see how things could have been much worse if I hadn't gotten to the hospital when I did." B) "I understand why they're not letting me eat anything for the time being." C) "I'm starting to see how my lifestyle has caused me to end up here." D) "My intravenous drip will keep me from getting dehydrated right now."

A client being prepared for discharge to home will require several interventions in the home environment. The nurse informs the discharge planning team—consisting of a home health care nurse, physical therapist, and speech therapist—of the client's discharge needs. This interaction is an example of which professional nursing relationship? A) Nurse-nurse B) Nurse-client-family C) Nurse-health care team D) Nurse-client

A client has just consumed a serving of ice cream and develops severe cramping and diarrhea. Which additional information will the nurse obtain to determine if the client has lactose intolerance? A) results of a stool sample test B) the client's vital signs C) what other symptoms the client is experiencing D) amount of fiber the client has ingested

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? A) As soon as possible after the client's surgery B) Once the client is admitted to the nursing unit from postanesthetic recovery C) On the client's admission to the hospital D) Once the client has received a discharge order

A female client has developed an abscess following abdominal surgery, and her food intake has been decreasing over the past 2 weeks. Which laboratory finding may suggest the need for nutritional support? A) Low random blood glucose levels B) Increased white blood cells C) Low serum albumin levels D) Proteinuria

A nurse follows set guidelines for administering pain medication to clients in a critical care unit. This nurse's authority to initiate actions that normally require the order or supervision of a physician is termed: A) collaborative orders. B) protocols. C) standing orders. D) nursing interventions.

Which guideline for composing a nursing diagnosis statement is correct? A) Incorporate subjective and judgmental terminology. B) Place the etiology prior to the client problem and link it by the phrase "related to." C) Place defining characteristics after the etiology and link them by the phrase "as evidenced by." D) Phrase the nursing diagnosis as a client need.

Which nursing action is applicable to the psychomotor domain of learning when conducting a teaching session for breastfeeding mothers? A) Advising the mothers to drink plenty of water B) Showing charts to the mothers that illustrate the types of breast milk C) Observing a mother expressing the breast milk D) Telling the mothers to avoid taking over-the-counter drugs while breastfeeding

Which statement appropriately identifies a risk nursing diagnosis for a client who is confined to bed? A) Potential for Pneumonia related to inactivity B) Ineffective Airway Clearance related to bed rest C) Risk for Impaired Skin Integrity related to bed rest D) Immobility related to confinement to bed

Which tasks can the nurse appropriately delegate to the unlicensed assistive personnel (UAP)? Select all that apply. A) Assess the client's need for education. B) Administer routine oral medications. C) Assist the client to the bedside commode. D) Record the client's intake and output. E) Assess the client's risk for pressure injuries.

C, D

A nurse is caring for a client receiving total parenteral nutrition (TPN). Which should the nurse educate the client about regarding TPN therapy? Select all that apply. A) TPN is an isotonic solution. B) Lipids are added to decrease caloric value. C) TPN has three primary components: proteins, carbohydrates, and fats. D) TPN has a high glucose concentration. E) TPN requires a PICC line or central venous access.

C, D, E

An older adult client has a history of constipation and currently self-treats with over-the-counter laxatives. What should the nurse educate the client regarding the use of laxatives? Select all that apply. A) All older adults should use laxatives to promote normal defecation. B) Oral laxatives take longer to work than laxatives administered rectally. C) Rectal suppositories need to be retained in the rectum for at least 15 minutes. D) Older adults are at a higher risk for laxative misuse and abuse. E) Incorporate higher fiber containing foods in the diet and increase fluid intake.

C, D, E, B

The nurse is caring for a client who has just had a lower leg amputation following a motor vehicle accident. During the planning phase of the nursing process, the nurse will prioritize which problem(s) on the first postoperative day? Select all that apply. A) Feelings of loss of power B) Altered body image perception C) Infection risk D) Caregiver fatigue E) Impaired coagulation potential

C, E

The older adult client reports back pain, and an aquathermia heating pad has been prescribed for comfort. What action(s) will the nurse perform to provide a safe application of heat therapy for this client? Select all that apply. A) Instruct the client to lie on the pad to keep the pad in its proper position. B) Check the heating pad is set between 98°F to 105°F (36.6°C to 40.5°C). C) Assess the client's skin prior to the application of heat. D) Apply the heating pad to the client's back for intervals of 1 hour. E) Ensure that the aquathermia unit contains water to the appropriate level.

C, E

The nurse formulates the nursing diagnosis: Disturbed Body Image related to decreased ability to cope with surgical removal of right breast as evidenced by client refuses to look at surgical site and client statement, "I'm ugly. My husband will no longer find me desirable." The decreased ability to cope with the removal of the breast is an example of: A) problem. B) NANDA-I label. C) defining characteristics. D) etiology.

The nurse has an order to obtain a 24-hour urine specimen from a client. Which instruction would be accurate for collection of the specimen? A) "You will need to have a catheter inserted for this collection." B) "Start collecting the urine with the next time you urinate." C) "Begin the collection when you first urinate in the morning." D) "Discard your first urine and begin the collection after that."

The nurse is assessing the client's abdominal wound and notes yellow-green purulent wound drainage. The nurse recognizes that the drainage is an example of: A) a judgment. B) an inference. C) subjective data. D) objective data.

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? A) a wound left open for several days to allow edema to subside B) a wound healing naturally that becomes infected. C) a large wound with considerable tissue loss allowed to heal naturally D) a surgical incision with sutured approximated edges

The nurse is caring for a client who has two Jackson-Pratt drains following her bilateral mastectomy. When emptying a Jackson-Pratt drain, the nurse should prioritize what action? A) Pin the drain to the client's gown after pulling the tubing taut. B) Don sterile gloves before manipulating the cap of the drain. C) Cleanse the area around the cap with alcohol for 30 seconds before removing it. D) Recompress the drain before replacing the cap.

Which client outcome is an example of a physiologic outcome? A) The client explains how to administer a vaginal cream. B) The client demonstrates active range-of-motion exercises with left upper extremity. C) The client reports walking for 30 minutes each day. D) The client's pulse oximetry reading is 97% on room air 30 minutes after removal of a nasal cannula.

Which factor is related to developmental changes in bowel habits for older adult clients? A) Increase in dietary fiber can decrease peristalsis. B) Older adults should peel fruits before eating. C) Milk products cause constipation in clients with lactose intolerance. D) Weakened pelvic muscles lead to constipation.

Which group of terms best defines assessing in the nursing process? A) Designing a plan of care, implementing nursing interventions B) Nurse-focused, establishing nursing goals C) Problem-focused, time-lapsed, emergency-based D) Collection, validation, communication of client data

A nurse is assessing the urine output of a client with Parkinson disease who is on levodopa. Which sign is a common finding for a client on this medication? A) The urine may be brown or black. B) The urine may be orange or orange-red. C) The urine may be green or blue-green. D) The urine may be blood-tinged.

A nurse is evaluating the outcomes of a plan of care to teach an obese client about the calorie content of foods. What type of outcome is this? A) Cognitive B) Physiologic C) Psychomotor D) Affective

A nurse is caring for an older adult client who is admitted with failure to thrive. Which laboratory value would the nurse expect to find with this diagnosis? A) Creatinine 1.5 mg/dL (132.6 mmol/L) B) Prealbumin 43 mg/dL (0.062 mmol/L) C) Serum albumin 4.8 g/dL (6.96 mmol/L) D) Blood urea nitrogen 15 mg/dL (5.35 mmol/L)

A nurse is explaining the purpose of nursing diagnoses to a client. What would be the most appropriate statement for the nurse to make? A) "Nursing diagnoses are used to guide the nurse in selecting appropriate nursing interventions." B) "Nursing diagnoses are used to bill insurance for client care." C) "Nursing diagnoses are necessary to schedule the amount of care required by the client." D) "Nursing diagnoses are necessary to validate the medical diagnosis."

A nurse is performing an assessment on a client in which the nurse categorizes the data according to various categories of functions. Which assessment model is the nurse using? A) Prevention B) Maslow's hierarchy C) Medical D) Gordon's functional health patterns

A nurse is preparing a client for colon surgery. Which teaching should the nurse provide first to prepare the client for what to expect after surgery? A) The nurse will listen to the bowel sounds regularly. B) The nurse will assess the pulse. C) The nurse will measure the urinary output. D) The nurse will check the skin turgor.

A nurse is reviewing a client's laboratory values. Which laboratory value would be indicative of a client's level of malnutrition? A) Serum albumin B) Creatinine C) Hemoglobin D) Oxygen saturation

A nurse tells a client, "Are you going to get out of bed, or are you just going to sleep all day and night?" This is an example of which barrier to communication? A) Using judgmental or belittling language B) Using leading questions C) Using comments that give advice D) Using probing questions

A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome? A) "Client will learn to cope more effectively." B) "Client tries using relaxation as a means to cope." C) "Client will list positive coping strategies and use them." D) "Client will identify one coping strategy to try by end of week."

A woman age 76 years has informed the nurse that she has begun using over-the-counter laxatives because her friend told her it was imperative to have at least one bowel movement daily. How should the nurse best respond to this client's statement? A) "Actually, people's bowel patterns can vary a lot and some people don't tend to go every day." B) "Most older adults only have a bowel movement every 2 to 3 days, actually, so I'd encourage you to taper off your laxatives." C) "Your friend is correct in her assessment, but it would likely be better to exercise and drink more instead of using medications." D) "That's correct, but be sure that you don't increase your laxative doses over time."

The nurse is preparing to insert an indwelling urinary catheter into a female client's bladder. The nurse has opened the sterile catheterization tray using sterile technique, donned sterile gloves and has opened all sterile supplies. Arrange the following steps in the correct order. 1) Insert the lubricated catheter into the urethra. 2) Discard used supplies. 3) Clean each labial fold, then the area directly over the meatus. 4) Inflate the balloon with the correct amount of sterile saline. 5) Advance the catheter until there is a return of urine.

3, 1, 5, 4, 2

After data collection on a client, the nurse suspects that the client has diarrhea. Which data collection finding, if observed by the nurse, would confirm the nurse's suspicion? A) Hyperactive bowel sounds B) Visible waves of abdominal peristalsis C) Increased anal area pigmentation D) Dry, hard stool

An unconscious client is brought to the emergency department. Which assessment should the nurse implement first? A) Determine if the airway is clear. B) Monitor the respiratory rate and pattern. C) Auscultate breath sounds. D) Obtain a pulse oximetry reading.

At the end of the shift, the nurse documents that the client has voided 475 mL during the shift via an indwelling urinary catheter. What type of data has the nurse documented? A) Objective B) Symptomatic C) Covert D) Subjective

Before discharge the client will demonstrate aseptic dressing changes. This is an example of which type of evaluative statement? A) Psychomotor B) Cognitive C) Affective D) Physical changes

Which are examples of breaches of client confidentiality? Select all that apply. A) A nurse shares his or her computer password with another nurse who was unable to log in to the system. B) A nurse uses a computer to document a client's response to pain medication. C) A nurse updates the employer of a client regarding the client's date of return to work. D) A nurse discusses information about a client with a coworker in the elevator. E) A nurse checks the health record of a client to see who is the contact person for an emergency.

A, C, D

The nurse is providing care to a postoperative client who has a Jackson-Pratt (JP) drain. The nurse notes that the JP drain is expanded and full of sanguineous fluid. Place in order the steps the nurse will now perform. 1) Empty the JP's contents into a graduated collection container. 2) Note the amount of output, as well as its color. 3) Compress the chamber and replace the JP cap. 4) Remove gloves and sanitize or wash hands. 5) Don clean gloves.

5, 1, 3, 2, 4

A 33-year-old client is brought to the urgent care center, doubled over in pain and crying. Upon assessment, the client admits to nausea and vomiting ×3 during the morning. Which action should the nurse prioritize after noting right lower quadrant (RLQ) rebound tenderness, blood pressure of 130/92 mm Hg, and pulse 100 beats/min and weak? A) Notify the health care provider immediately B) Send the client to the closest emergency department C) Start an IV of normal saline D) Reevaluate the client in 30 minutes

A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this? A) maturation B) primary intention C) tertiary intention D) secondary intention

A nurse writes the following nursing diagnosis for a client with Alzheimer disease: Disturbed Thought Processes related to Alzheimer disease as evidenced by incoherent language. Which part of this diagnosis is considered the problem statement? A) Incoherent language B) Alzheimer disease C) Related to D) Disturbed Thought Processes

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? A) Human Response Patterns B) Functional Health Patterns C) Body Systems Model D) Hierarchy of Human Needs

A client with diabetes mellitus has been admitted to the intensive care unit with a serum glucose reading of 400 mg/dL (22.20 mmol/L). Because the care for this client will involve multiple disciplines, which diagnostic statement would be most appropriate for the nurse to select? A) Diabetes Mellitus as evidenced by serum glucose of 400 mg/dL (22.20 mmol/L) B) Need for Glucose Control as evidenced by hyperglycemia C) Risk for Unstable Blood Glucose related to diabetes D) PC: Hyperglycemia related to uncontrolled serum glucose

A nurse is caring for a postsurgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider? A) large amounts of drainage that is clear and watery and has no smell B) copious drainage that is blood-tinged C) small amount of drainage that appears to be mostly fresh blood D) foul-smelling drainage that is grayish in color

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