Prep u questions for Hygiene, nursing process,

assessment, diagnosis, planning, implementation, and evaluation

The correct progression of steps of the nursing process is: a. diagnosis, implementation, assessment, evaluation, and planning b. planning, assessment, diagnosis, evaluation, and implementation c. implementation, planning, evaluation, assessment and diagnosis d. assessment, diagnosis, planning, implementation, and evaluation

skin

The first line of defense against microorganisms and infection from entering the body is the person's: a. skin b. gastrointestinal tract c. mucous membranes d. hair

assessing the wound for active bleeding

The health care provider prescribes negative pressure wound therapy for a client with a pressure injury. Before initiating the treatment, it is important for the nurse to implement which nursing assessment? a. assessing the wound for active bleeding b. assessing for claustrophobia c. assessing for the use of antihypertensives d. assessing the client's mental status

implementation

The nurse administers pain medication to a postoperative client. In which phase of the nursing process is this occurring? a. implementation b. assessment c. nursing diagnosis d. planning

proliferation

Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue bleeds easily when the nurse performs wound care. What is the phase of wound healing chaterized by the nurse's assessment? a. maturation phase b. inflammatory phase c. hematosis d. proliferation phase

focused

Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative a cholecystectomy? a. emergency b. focused c. time lapse d. initial

stage 2 pressure injury

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open injury with a red pink wound bed and partial thickness loss of dermis. What is the correct name of this wound? a. stage 4 pressure injury b. stage 1 pressure injury c. stage 3 pressure injury d. stage 2 pressure injury

medication listed on the client's medication administration record (MAR)

A 55 year old client has just undergone surgery for a knee replacement. He asks the nurse if he can shave because his face is itching form the stubble. What information is a priority for the nurse to verify prior to shaving the client? a. the last time shaving was performed b. cultural views and attitudes toward facial hair and grooming c. client's allergies to soap since shaving cream is contraindicated in the hospital d. medication listed on the client's medication administration record (MAR)

assessing

A client comes to the emergency department reporting severe chest pain. The nurse asks the client questions and takes vital signs. Which step of the nursing process is the nurse demonstrating? a. planning b. implementing c. assessing d. diagnosing

auscultating anterior and posterior lung sounds

A client has arrived in the emergency by ambulance and is reporting shortness of breath. After placing the client on oxygen and contacting the physician, which is the priority action of the nurse? a. transporting the client for chest x ray b. taking vital signs c. auscultating anterior and posterior lung sounds d. percussing the thorax bilaterally

sordes

A client who has been admitted in the health care facility has had surgery and is unconscious. The nurse needs to take care of the client's hygiene and oral care daily. The client's teeth and lips show dry crusts when there is a days gap in the oral hygiene. What can best describe the client's oral condition? a. gingivitis b. periodontal disease c. caries d. sordes

client will have formed stools within 24 hours

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem? a. client will eat small meals of bland foods for 3 days b. client will maintain adequate hydration within 2 days c. client will identify the food that caused the condition within 3 hours d. client will have formed stools within 24 hours

hydrocolloid dressing

A health care provider orders a dressing to cover a newly develop partial thickness wound with minimal drainage. What would be the best type of dressing for this wound? a. foam dressing b. dressing secured with montgomery straps c. hydrocolloid dressing d. saline moistened dressing

the client

A nurse assesses a client, obtaining the information from a primary source. The nurse has gathered the information from which source? a. the client's spouse b. the client's heal the care records c. a primary care physician d. the client

ongoing planning

A nurse assesses the vital signs of a client who is one day postoperative following a colostomy. The nurse then uses the data to update the client plan of care. What are these actions considered? a. discharge planning b. initial planning c. comprehensive planning d. ongoing planning

a separation of skin and tissue in which the edges are torn and irregular

A nurse caring for a female client notes a number of laceration wounds around the cervix of the uterus due to birth. How could the nurse describe the laceration wound in the client's medical record? a. clean separation of skin and tissue with a smooth, even edge b. a shallow crater in which skin or mucous membrane is missing c. a separation of skin and tissue in which the edges are torn and irregular d. a wound in which the surface layers of skin are scraped away

full thickness

A nurse is assessing a client with a stage IV pressure injury. What assessment of the injury would be expected? a. blister formation b. skin pallor c. eschar formation d. full thickness

assisting the client in moving to prevent strain on the suture line

A nurse is caring for a client who is 2 days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time? a. preventing scare formation so it does not limit joint movement b. assisting the client in moving to prevent strain on the suture line c. administering pain indications on a p.r.n. and regular basis d. telling the client that a mild fever is a normal response

aspiration

A nurse is caring for a client who is receiving care for a traumatic head injury that has rendered the client unconscious. When providing mouth care for this client, the nurse muse be cognizant of the client's risk for: a. aspiration b. coughing c. fluid volume over load d. dental caries

the client should be place in a side lying position to prevent aspiration

A nurse is caring for a client with a decreased level of consciousness (LOC). When performing mouth care, what action by the nurse will decrease complications of oral care? a. the client should be place in the lithotomy position b. the client should be placed in a position of comfort c. the client should remain in a upright position to avoid the tongue blocking the airway d. the client should be place in a side lying position to prevent aspiration

the client hears vibrations in the affected ear

A nurse is conducting an auditory assessment of an older adult with conductive hearing loss. The nurse performs the webber test. Which finding would the nurse nurse expect to assess in this client? a. the client hears sound that is lateralized to the unaffected ear b. the client hears vibrations equally in both ears c. the client hears vibrations in the affected ear d. the client hears a hyper resonant sound in the ears

store dentures in cold water when not in use

A nurse is educating a client on how to care for dentures. What is a recommended teaching guideline? a. store dentures in cold water when not in use b. remove dentures whenever possible to rest the gums c. wrap dentures in a napkin when not using them d. keep dentures in the bed for easy assess

bathing reduces the possibility of infection

A nurse is explaining the need for bathing to an elderly client who has been avoiding a daily bath. Which benefit of bathing should the nurse explain to the client? a. bathing keeps mucous membranes soft and moist b. bathing maintains the body temperature c. bathing prevents skin from peeling d. bathing reduces the possibility of infection

in effective airway clearance related to thick mucus

A nurse is formulating a nursing diagnosis for a client with a respiratory disease. Which nursing diagnosis would be correct? a. cough related to in effective airway clearance b. refuses to cough and expect to rate thick mucus c. in effective airway clearance related to thick mucus d. needs nasal oxygen to improve breathing

a laceration

A nurse is inspecting the skin of a client and notes a wound with ragged edges and torn tissue. The nurse documents this wound as: a. a contusion b. a puncture c. a laceration d. an abrasion

stand 2 feet behind and to the side of the client

A nurse is performing a whisper test on an elderly client. How should the nurse complete this assessment? a. stand 2 feet behind and to the side of the client b. stand in front of the client and have them close their eyes c. place headphones on the client to listen for recorded sounds d. place a vibrating form on top of the clients head

dorsal recumbent

A nurse is preparing to examine the breasts of a client. In what position should the nurse place a client?

side lying

A nurse is preparing to provide oral care to a client who is unconscious. The nurse would place the client in which position? a. high fowler's b. supine c. side lying d. trendelenburg

clients with diabetes

A nurse is providing nail care to clients admitted to a health care facility. The nurse should know that which clients are most susceptible to nail problems? a. clients with fever b. clients with sinusitis c. clients with diabetes d. clients with diarrhea

shave with the direction of hair growth

A nurse is shaving the facial hair of a client confined to bed. What is a recommended guideline for the procedure? a. shave with the direction of hair growth b. apply shaving cream approximately 1 inch thick c. do not use aftershave or lotion on the area shaved d. fill bath basin with cool water

sit down shower with shower chair

A nurse is taking care of an older adult woman who demonstrates good mobility but is unable to stand for long periods of time secondary to muscle weakness. Which method for bathing would be most appropriate for this client? a. sit down shower with shower client b. stand up shower c. bed bath d. towel or bag bath

clean, using a washcloth, from the pubic area toward the anal area

A nurse is teaching a family member how to bathe the female bed bound client. What information should the nurse tell the client about perineal care? a. clean the labia with flushing water then proceed to the anal area with a wash cloth b. clean the area surrounding the labia and anal area with wash cloth before cleaning the labia and anus c. clean the perianal region with designated hospital grade disposable wipes d. clean, using a washcloth, from the pubic area toward the anal area

secondary intention

A nurse is treating a client who has a wound will pull 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. primary intention b. tertiary intention c. secondary intention d. maturation

from the public area toward the anal area

A nurse providing perineal care to a female client. In which direction would the nurse move the washcloth? a. the direction does not make a difference b. from the anal area to the pubic area c. from side to side within the labia d. from the pubic area toward the anal area

provide supplies and assist with hard to reach areas

A student has been assigned to provide morning care to a client. The plan of care includes information that the client requires partial care. What will the student do? a. provide supplies and assist with hard to reach areas b. provide supplies and orient the client to the bathroom care c. provide total physically hygiene, including hair care d. provide total physically hygiene, excluding hair care

following a bath

According to common practice, when are the bed linens usually changed? a. after receiving visitors b. following a bath c. before bed d. before giving the bath

actual

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? a. possible b. risk c. health promotion d. actual

hierarchy of human needs

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.Hierarchy of Human needs b. Human Resource patterns c. functional health patterns d. body system model

it helps holistic, goal oriented, individualized care

After the health history and admission assessment are completed, the nurse established a care plan for the client. What is the rationale for documenting and planning the client's care? a. it creates a teaching for family b. it helps, holistic, goal oriented, individualized care c. it verifies staffing d. it provides the client with information

store the client's dentures in water when the client is not wearing them

An older adult client has been admitted to the hospital with acute delirium and is temporarily unable to take care of her own dentures. How should the nurse care for the client's dentures? a. arrange for a minced or pureed diet for the client so that dentures in are not necessary b. store the client's dentures in water when the client is not wearing them c. send the dentures home with a friend or family member until the client is discharged d. encourage the client to wear her dentures 24 hours a day to prevent their loss

transparent film

An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm in order to facilitate rehydration What type of dressing should the nurse apply over the client's venous access site? a. transparent site b. a gauze dressing precut halfway to fit around the IV line c. a dressing with a non adherent coating d. a gauze dressing premeditated with antibiotics

Cleanse to remove secretions from less soiled to more soiled areas.

An older adult client with Parkinson's disease is unable to take care of himself. The client frequently soils his bed and is unable to clean himself independently. How should the nurse in this case ensure the client's perineal care? a. provide the client with a bed pan or jar to collect the urine b. cleanse using a cotton cloth and warm water c. use tissue rolls to clean the clients perineal are d. Cleanse to remove secretions from less soiled to more soiled areas.

when the client's last tub bath was

An older client is reporting dry, itching skin. The nurse should assess: a. when the client's last bath was b. what linens they are using c. how often the client is bathing d. when the severe itching started

objective

At the end of the shift, the nurse documents that the client has avoided 475 mL during the shift via an indwelling urinary catheter. What type of data has the nurse documentation? a. objective b. symptomatic c. subjective d. covert

constriction of the pupils

During a physical exam, the nurse assesses a client's eyes for the accommodation response. When looking at a near object, What would the nurse observe for? a. consensual light reflex b. convergence of the eyes c. contrition of the pupils d. conjugate movement of the eyes

5 minutes

During an abdominal assessment the nurse is unable to hear bowel sounds in a client's right lower quadrant. How long should the nurse listen before documenting absent bowel sounds? a. 30 seconds b. 5 minutes c. 1 minute d. 8 minutes

a client who is obese and has a diagnosis of type 1 diabetes

For which client is foot care likely the priority? a. a client who has chronic renal failure and requires hemodialysis 3 times per week b. a client who is obese and has a diagnosis of type 1 diabetes c. a client who has experienced postoperative pneumonia and has been placed on a ventilator d. a client who has been diagnosed with Alzheimer disease and whose mobility is decreasing

partial care

The nurse assists the client to the bathroom sink to perform morning care. The nurse observes the client wash his face, arms, abdomen, and legs. The nurse washes the client's back and rectal area and applies soap to the back. The client brushes his teeth and ambulates to a chair in his room with assistance. How will the nurse describe the morning care on the client's chart? a.partial care b.self care c. as needed care d. complete care

gauze

The nurse has collected blood from a client for laboratory analysis. Which dressing will the nurse select to cover the site from which the blood was drawn? a. gauze b. hydrocolloid c. tape with eyelets d. transparent

human needs (Maslow) model

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 response patterns model b. functional health patterns model c. body system model d. human needs (maslow) model

an obese woman with a history of type 1 diabetes

The nurse would recognize which client as being particularly susceptible to impaired wound healing? a. an obese woman with a history of type 1 diabetes b. a man with a sedentary lifestyle and a long history of cigarette smoking c. a client whose breast reconstruction surgery required numerous incisions d. a client who is NPO (nothing by mouth) following bowel surgery

physiological

The nursing diagnosis impaired Gas Exchange, prioritized by Maslow's hierarchy of basic human needs, is appropriate for what level of needs? a. safety b. love and belonging c. physiological d. self actualization

help the client achieve optimal levels of health

The primary purpose of nursing implication is to: a. improve the client's operative status b. help the client achieve optimal levels of health c .identify a need for collaborative consults d. implement the critical pathway for the client

identify actual and potential health problems

The purpose of obtaining a nursing history is to: a. identify actual and potential health problems b. assist the physician to establish a medical diayalsis c. minimize the times required to establish a nursing diagnosis d. focus on objective physical data specific to the client

look at a close object, then a distant object

To assess a client's visual accommodation, the nurse has a client: a. stand 20 feet from the shelled chart b. sit still while a penlight is shined at the pupil c. look at a close object, then a distant object d. look straight ahead with one eye covered

wheezes

Upon auscultation of a client's lung fields, the nurse hears a continuous high pitched sound on expiration. These are characteristics of which adventitious breath sound? a. fine crackles b. pleural friction rub c. wheezes d. stertorous breathing

covering the wound area with sterile towels moistened with sterile 0.9% saline

Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. Initial nursing management includes calling the healthcare providers

critical thinking

What is a systemic way to form and shape one's thinking? a. intuitive thinking b. critical thinking c. trial and error d. interpersonal values

to design a plan of care for and with the client

What is the primary purpose of the outcome identification and planning step of the nursing process?

hydrocolloid dressing

What type of dressing has the advantage of remains in place for three to seven days, resulting in less interference with wound healing? a. hydrogel b. hydrocolloid dressing c. alginate d. transparent film

incision

When assessing a wound that a client sustained as a result of surgery, the nurse notes well approximated edges ad no signs of infection. How will the nurse document this assessment finding? a. incision b. laceration c. avulsion d. abrasion

shearing force

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of decubitus ulcers. What is the name given to the factor responsible for this risk? a. ischemia b. friction c. shearing force d. necrosis of tissue

dull

When percussing the liver, the sounds should be: a. flat b. resonant c. hyperresonant d. dull

the nurses should determine the client's normal bowel elimination pattern

When reviewing the client's history, the nurse notes that the client's last document bowel movement was 2 days ago. Before the nurse identifies a diagnosis of "constipation", what assessment must the nurse make? a. the nurse should assess the client's bowel sounds b. the nurse should determine the standard bowel elimination pattern pattern for the clients age c. the nurse should assess the client's dietary habits d. the nurses should determine the client's normal bowel elimination pattern

focused

When the nurse inspects a postoperative incision site for infection, which type of assessment is the nurse performing? a. complete b. time lapse c. focused d. general

laboratory test results

Which are examples of objective data?select all that apply? a. client's report of being unable to breathe b. a client's report pain c. a client's temperature d. laboratory test results e. breath sounds on auscultation

light headedness, anxiety, nausea

Which are examples of subjective data?Select all that apply. a. laceration b. edema c. light headedness d. anxiety e. nausea

body systems framework

Which framework is used during the focused assessment? a. conceptual framework b. body systems framework c. head to toe framework d. functional health assessment

place defining characteristics after the etiology and link them by the phrase "as evidenced by"

Which guide line for composing a nursing diagnosis statement is correct? a. phrase the nursing diagnosis b. place defining characteristics after the etiology and link them by the phrase as evidenced by c. incorporate subjective and judgemental terminology d. place the etiology prior to the client problem and link it by the phrase "related to"

it is a framework for providing care

Which is a characteristic of person centered care? a. it involves general care for all clients b. it can be used in hospital settings c. it is a framework for providing care d. it is independent of other disciplines

adds depth to existing information

Which is the purpose of a focused assessment? a. adds depth to existing information b. suggests possible problems c. gives a comprehensive volume of data d. provides breath for future comparison

the nurse assess the client's response to pain medication

Which nursing action reflects evaluation? a. the nurse identifies that the client has wound drainage b. the nurse assess the client's response to pain medication c. the nurse performs colostomy irrigation d. the nurse sets an anxiety level of 3 or less with the client

ineffective breathing patterns

Which nursing diagnosis the priority? a. ineffective breathing patterns b. anxiety c. stress in continence d. spiritual distress

nurse initiated interventions are derived from the nursing diagnosis

Which state correctly describes a nurse initiated intervention? a. nurse initiated interventions are actions deemed to have a low risk of harm to the client b. nurse initiated interventions are actions performed to diagnose a medical problem c. nurse initiated interventions are derived from the nursing diagnosis

S3 is confided normal in children and young adults in middle aged and older adults

Which statement accurately represents a characteristic of the third or fourth heart sound? a. S4 is the fourth heart sound, represented by "lub dub dee b. S4 is considered normal in children and adults but abnormal in older adults c. S3 is considered normal in children and young adults in middle ages and older adults d. S3 is best heard with stethoscope bell at the mitral area, with the client lying on the right side

diagnosis

Which step of the nursing process involves reporting or analysis of data to identify and define health problems? a. implementation b. diagnosis c. planning d. assessment

palpate the pulse for 1 minute

Which technique should the nurse use when assessing the radial pulse of a client with a history of atrial fibrillation? a. palate the pulse is 15 seconds and multiply by 4 b. palpate the pulse for 1 minute c. palpate the pulse for 2 minutes d. palpate pulse for 10 seconds and multiply by 6