Test 2 Study Material - Fundamentals

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A client is admitted to the hospital with an abscess on the leg that will not heal after multiple treatment options as an outpatient. The nurse knows from past experiences that the appearance of this type of wound in clients heavily suggests a resistant bacterial infection and the need for contact isolation and intravenous antibiotics. The nurse begins to prepare for this admission. What type of problem solving does this exhibit? A. Intuitive B. Experiential C. Scientific D. Trial-and-error

A client is asking for the nurse to explain acupuncture. What would the nurse tell the client? A. Acupuncture is used to correct disharmony. B. Acupuncture is beneficial to creating a mood of distraction. C. Acupuncture is only done in Eastern countries. D. Acupuncture is a dangerous option for the treatment of disease.

A client is brought to the emergency department in an unconscious state with a head injury. The client requires surgery to remove a blood clot. What would be the appropriate nursing intervention in keeping with the policy of informed consent prior to a surgical procedure? A. The nurse ensures that the client's family signs the consent form. B. The nurse informs the family about the living will. C. The nurse informs the family about advance directives. D. The nurse ensures that the client signs the consent form.

A client is having an increasing amount of difficulty caring for oneself in the home alone. The client states to the nurse, "I need more help. What am I going to do?" Which action would be the most appropriate for the nurse to take? A. Have the social worker visit the client to discuss care options. B. Have the physical therapist help the client with rehabilitation. C. Have the occupational therapist assess for the client's need for adaptive devices. D. Have the home health aide increase visits for bathing the client.

A client scheduled to have hip replacement surgery states, "I am so scared of the surgery and of the anesthetic." What is the best response by the nurse? A. "What questions do you have about the surgery?" B. "Your wife will be in the surgery waiting room the entire time." C. "You really don't have anything to worry about." D. "What will happen if you don't have surgery?"

A client states that the client's recent fall was caused by his scheduled antihypertensive medications being mistakenly administered by two different nurses, an event that is disputed by both of the nurses identified by the client. Which measure should the nurses prioritize when anticipating that legal action may follow? A. Document the client's claims and the events surrounding the alleged incident. B. Consult with practice advisors from the state board of nursing. C. Consult with the hospital's legal department as soon as possible. D. Enlist support from nursing and nonnursing colleagues from the unit.

A client suffering from infectious diarrhea, dehydration, and right-sided paralysis is confined to bed. What is the client most prone to? A. decubitus ulcer B.bowel obstruction C.depression D.urinary incontinence

A client was admitted to a postoperative nursing unit after undergoing abdominal surgery. During this time, the nurse failed to recognize the significance of abdominal swelling, which significantly increased during the next 6 hours. Later, the client had to undergo emergency surgery. The lack of action on the nurse's part is liable for action. Which legal term describes the case? A. Tort B. Misdemeanor C. Felony D. Fraud

A home health nurse states to her client, "I am very proud of you. You gave your first insulin injection without a problem. You have done wonderfully and are learning fast." What technique is the nurse using to compliment the client's progress? A. Positive feedback B. Motivation C. Reinforcement D. Health promotion

A new client arrived on the unit while the nurse was obtaining the end-of-shift report from the night nurse. This client is admitted walking and is here for a cardiac workup; the client is assigned to the nurse. The nursing assistant has settled the client in the room and oriented the client to the surroundings, call system, bathroom, bedside supplies, and where to place clothes. The priority nursing action is to: A. gather information and complete the admission database. B. obtain the physician's orders. C. ask the nursing assistant to obtain vital signs. D. call the dietary department to get breakfast for the client.

A new nurse is considering getting a job in either an acute care setting or a home care setting. Which statement about these care settings is most accurate? A. Clients play a large role in helping themselves in the home care setting. B. Good communication skills are unnecessary in the home care setting. C. Nurses work more as team members in the home care setting. D. Clients are encouraged to help each other in the acute care setting.

A nurse demonstrates understanding of Healthy People 2020: Understanding and Improving Health by supporting which statement? A. A client's health is affected by social, economic, and political factors. B. Establish a set of nursing skills that focuses on quick resolution to clients' needs. C. Clinical care supports wellness in the environment. D. Physical therapy supports client safety at home.

A nurse has an older adult home care client who lives alone with no family nearby. On a recent visit, the nurse notices that his clothes are very loose, and he has difficulty letting the nurse leave when the visit is ending. After talking with him, the nurse learns that he has not been cooking for himself and he can't get to the grocery store easily. What service could the nurse suggest as an immediate response until a long-term plan can be formed? A. Enroll the client in Meals on Wheels. B. Refer him to the dietitian. C. Suggest he go to an assisted living facility. D. Have the social worker counsel him.

A nurse has very strong client education skills. In which health care setting would the nurse make best use of these skills? A. Primary care center B. Emergency department C. Teritary care medical center D. Same-day surgery unit

A nurse in a rural health center meets a new client, age 4. The nurse notices as the client enters the clinic that his legs appear to be bowed. When he smiles, the nurse also notes that his dentition is quite malformed for a child his age. What vitamin deficiency would the nurse most suspect? A. vitamin D B. vitamin B C. vitamin A D. vitamin C

A nurse is asking a colleague about a situation. Which statement demonstrates assertive communication? a. "I think there is a better way to handle this." B. "You always act like this." C. "What is your problem with me?" D. "Why are you treating me this way?"

A nurse is assessing a client who has come to the clinic for a follow-up appointment. The client was diagnosed with asthma several months ago and has missed several appointments since that time. The client also has not been following the medication plan and has not kept the appointment for allergy testing. The nurse suspects that the client may be experiencing problems with health literacy. The nurse teaches the client about the condition and prescribed treatment. Which question from the nurse would help to assess the client's health literacy about the condition? A. "How are you supposed to take your medication?" B. "Are you having trouble getting your medications filled?" C. "Do you have any questions about what you are supposed to do?" D. "Do you understand what asthma is?"

A nurse is assessing the nutritional needs of clients. Which criteria indicates that a client most likely needs total parenteral nutrition (TPN)? A. wasting syndrome from AIDS B. Serum albumin level of 4.2 g/dL (3.63 mmol/L) or less C. Presence of dumping syndrome D. Residual of more than 100 mL

A nurse is calling a physician to communicate a change in the client's condition. According to the ISBARR format for handoff communication among health care personnel, which is the most appropriate way to begin the conversation? A. "My name is Sue Smith, RN, and I am calling regarding Mrs. Jones in room 356 at Jefferson Hospital." B. "My name is Sue, and I am calling about Mrs. Jones, a client of yours at Jefferson Hospital." C. "I have a client of yours at Jefferson Hospital who is experiencing a change in condition and needs to be seen immediately!" D. "Good morning, I am calling about Mrs. Jones, who is a client of yours."

A nurse is covering all aspects of admission procedures for a client who is receiving home health services. The nurse explains what procedures will be covered during the nurse's visits. Which aspect of the admission process does this represent? A. Clearly defining the purpose and expectations of the admission B. Documenting the procedure C. Assisting in participation of the care-related decisions D. Establishing rapport and showing willingness to listen

A nurse is discharging a client who was admitted for observation following a motor vehicle accident. The client is a single parent who is living in a new community. What service would be an appropriate referral for this client? A. Parish nursing B. Medical home C. Hospice care D. Respite care

A nurse is dressing the wound of a client who is admitted to the outpatient surgical unit. What is a major advantage of outpatient surgery? A. It interferes less with the client's daily routine. B. It requires intensive preoperative education in a short time. C. It allows less opportunity for family contact and support. D. It reduces the time for establishing a nurse-client rapport.

A nurse is reading an online journal article about different approaches to health. The nurse is reading about a practice approach that is supported by evidence-based practice and is particularly effective when aggressive treatment is needed in an emergency situation. The nurse is reading about which type of approach? A. Allopathic B. Ayurveda C. Naturopathy D. Traditional Chinese medicine

A nurse is reviewing the different types of health care delivery services available in the community. Which method would the nurse identify as having the primary care goal of reducing costs by preventing illness? A. Health maintenance organization (HMO) B. Community health center C. Preferred provider organization (PPO) D. Accountable care organization (ACO)

A nurse is teaching a client about healthy food choices using a holistic approach. The nurse determines that additional teaching is needed based on which client statement? A. "I can have a can of soda as often as I want to." B. "Natural sweeteners are better to use than artificial ones." C. "I'll reduce the amount of processed foods I eat." D. "Frozen foods are better to eat than canned foods."

A nurse manager is trying to resolve a conflict between the day and night shifts. The nurse manager wants to convince the involved persons to set aside their differences, determine a priority common goal having to do with improved client care, and accept mutual responsibility for achieving this goal. The nurse manager is using which type of conflict resolution? A. Collaborating B. Avoiding C. Compromising D. Competing

A nurse recommends palliative care for a client who is being discharged following a diagnosis of cancer. What is the chief focus of this type of care? A. Relief from physical, mental, and spiritual distress B. Occupational therapy C. Physical rehabilitation D. Provision of a dignified death experience

A nurse recommends palliative care for a client who is being discharged following a diagnosis of cancer. What is the chief focus of this type of care? A. Relief from physical, mental, and spiritual distress B. Provision of a dignified death experience C. Occupational therapy D.Physical rehabilitation

A nurse says, "We have so many drills and safety checks for everything. It is almost like we are preoccupied with the possibility of failure." How should the charge nurse respond to this statement? A. "Highly reliable organizations think about the possibility of failure and what to do to avoid it." B. "I agree with you. We need to focus more on the positive things we do instead of what could go wrong." C. "I am afraid that there may be an issue when our next accreditation visit occurs." D. "Which drills and safety checks do you think we could eliminate?"

A nurse working on a busy medical-surigcal unit does not take the vital signs of client who is preparing for discharge but instead documents the same vital signs obtained for this client earlier in the morning. For which tort would the nurse be potentially liable? A. Fraud B. False imprisonment C. Assault D. Battery

A nursing instructor is teaching a student nurse about the layers of the skin. Which layer should the student nurse understand is a potential source of energy in an undernourished client? A. Subcutaneous tissue B. Muscle layer C. Dermis D. Epidermis

A physician is called to see a client with angina. During the visit the physician advises the nurse to decrease the dosage of atenolol to 12.5 mg. However, because the physician is late for another visit, the physician requests that the nurse write down the order for the physician. What should be the appropriate nursing action in this situation? A. The nurse should ask the physician to come back and write the order. B. The nurse should inform the client of the change in medication. C. The nurse should remind the physician later to write the work order. D. The nurse should write the order and implement it.

A single parent age 17 years, with one child and pregnant with a second, has the mental age of a 12-year-old. The home care nurse's greatest concern in caring for this client should be the client's ability to do which? A. Cognitively understand how to care for the children B. Receive financial aid C. Physically perform care needed by the children D. Bond with the children

A staff nurse is talking with a clinical nurse leader and asks, "What exactly do you do?" Which statement by the clinical nurse leader wouid be appropriate? A. "I collaborate with health care teams to promote client care." B. "My position is one of management." C. "I'm an advanced practice nurse with a specific specialty area." D. "I'm an administrator involved with client care."

An active, otherwise healthy, older adult client presents to the clinic with severe osteoarthritis in both knees. The nurse knows this client does not want to be a burden on the family, and the client remains stoic despite reporting the pain as severe. The client avoids the topic of surgery and attends church weekly. The client's family is supportive of any decisions the client makes regarding health. Which of the assessment data is most important to forming an individualized education plan for this client concerning treatment for osteoarthritis? A. Personal perception of health and aging B. Formal religious beliefs C. Floor plan of the client's dwelling D. Orthopedic surgical history

An athlete wants to increase her intake of complex carbohydrates and asks the nurse about potential sources. Which food is considered a complex carbohydrate? A. Bread B. Molasses C. Syrup D. Brown sugar

An experienced nurse is educating a client about the client's disease and how best to promote optimal health. The nurse is focusing the education on the cognitive domain of learning. Given this focus, the nurse would incorporate the client's: A. critical thinking. B. physical demonstration. C. emotions or feelings. D. muscular movements.

Carl Rogers (1961) studied the process of therapeutic communication. Through his research, the elements of a "helpful" person were described. They include all of the following except which choice? A. analysis B. empathy C. comfortable sense of self D. positive regard

Conflict has emerged on a nursing unit due to the perception by new graduates that some of the more experienced nurses are manipulating the client assignment to ensure a lighter workload during night shifts. How should the manager of the unit best address this conflict? A. Arrange a meeting where the issue can be discussed and addressed by as many of the nurses as possible. B. Reassure the new graduates that the more experienced nurses are acting in the interests of both staff and clients. C. Gather evidence over the next several weeks in order to determine if the practice is indeed happening. D. Arrange for the newer nurses to organize the client assignment for a trial period.

Continuity of care for a particular client is most important to prevent: A. fragmentation of services. B. infection. C. multiple providers. D. rising health care costs.

During the inspection of a client's abdomen, the nurse notes that it is visibly distended. The nurse should proceed with the client's abdominal assessment by next performing: A. auscultation. B. light palpation. C. percussion. D. deep palpation.

On a medical unit, the nurses complain that they have no voice in the decisions that are made in the operation of the unit. The nurses state they are always told by the nurse manager to perform tasks instead of being asked. Which of these best describes the leadership style of the nurse manager? A. Autocratic B. Laissez-faire C. Democratic D. Nondirectional

On admission to the hospital, each client is asked whether the client has a living will or a durable power of attorney. If not, the admitting staff person provides a sample form to the client if wanted. The purpose of this inquiry is to determine: A. whether the client has a document describing wishes for care when the client is no longer able to make decisions. B. how the client feels about being resuscitated and maintained on life support if this is necessary. C. what the client wants to have happen during the hospitalization. D. previous decisions made regarding whom to contact should the client die in the hospital.

Select the best description of how the nurse applies the nursing process in caring for clients. The nurse: A. uses critical thinking to direct care for the individual client. B. applies intuition and routine care for clients. uses scientific problem C. solving to meet client problems. D. employs communication to meet the client's needs.

Several nurses on the same hospital unit communicate on the same social networking site. A nurse posts the following statement to the social networking page, "The lady in room 34 with heart failure was a train wreck!" This statement: A. is unacceptable and breaches the client's confidentiality rights. B. is unacceptable because the diagnosis of heart failure was listed. C. is acceptable because the client's name was not used. D. is acceptable because the hospital's name was not mentioned.

The chief nursing officer (CNO) wants to encourage nurses in the hospital to become clinical nurse leaders (CNL) and is reviewing a roster of nurses working on the medical-surgical unit. Which nurse should the CNO recognize as being qualified to take the CNL examination? A. An RN with an MSN who is a nurse manager, has 7 years of nursing experience, is supportive, and is engaged in community service activities B. An with a BSN who is a case manager; has 16 years of nursing experience, is trustworthy, and provides compassionate client care C. An RN with an ADN who is a charge nurse, has 5 years of nursing experience, is honest, and is enrolled in BSN courses D. An RN who attended a diploma program, has 20 years of nursing experience, is a bedside nurse, is reliable, and provides quality client care

The client reports to the nurse that she feels as if her eyes are persistently dry. This symptom is consistent with a deficiency in which dietary element? A. Vitamin A B. Protein C. Vitamin D D. Calcium

The community nurse is educating client groups about nutrition. Which group does the nurse identify that will benefit most from nutritional counseling and intervention? A. older adults living on a fixed income B. married, pregnant women over 30 years of age C. people who live in farming communities D. double income, married individuals

The goals of health care reform include which? A. Focussing on cost containment with improved access and quality of services for everyone B. Improving quality of care while limiting access for the uninsured to control rising costs C. Controlling health care costs by providing limited services for more consumers of health care D. Decreasing health care services to provide all citizens with some access to care but control escalating costs

The health care provider prescribes a high-fiber diet for a client to promote bowel elimination. Which foods, selected by the client, would indicate to the nurse that the client can identify high-fiber foods? A. Whole wheat spaghetti and broccoli B. Hot tea and flavored water C. Cream of wheat and applesauce D. Soda crackers and chicken noodle soup

The home care nurse visits a client and is reviewing the medications that the client uses. Which medication would the nurse identify as acting directly on the intestine to slow bowel motility, or to absorb excess fluid in the bowel? A. Antidiarrheal agent B. Antiflatulence agent C. Laxative D. Suppository

The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces? A. a client sitting in a chair who slides down B. a client who lies on wrinkled sheets C. a client who lifts himself up on his elbows D. a client who must remain on his back for long periods of time

The nurse in a medical unit is collecting a client's history and asks the client about the use of complementary and alternative therapies. The client asks why the nurse needs to know about this. What is the nurse's best response? A."It's important that we list all your home care needs for the hospital." B. "I am just curious on what types of treatments are used by people." C. "I want to make sure you understand all the risks of these treatments." D. "It will help me so that I can recommend use of these for other clients."

The nurse is advising a client about health problems related to being overweight. The client acknowledges the need to lose weight. The nurse provides education on how to count calories in food and the importance of daily exercise. The client states an intention to begin counting calories with the next meal. The client also states an intention to begin an exercise program with friends. Which statement associated with this scenario illustrates Lewin's stage of unfreezing? A. The client acknowledges the need to lose weight. B. The nurse provides education on how to count calories in food and the importance of daily exercise. C. The client states an intention to begin counting calories with the next meal. D. The client also states an intention to begin an exercise program with friends.

The nurse is assessing clients for postoperative complications. What is the most commonly assessed postanesthesia recovery emergency? A. Respiratory obstruction B. Wound infection C. Cardiac distress D. Dehydration

The nurse is caring for a client after a facial tumor was surgically removed. The primary care provider ordered a regular diet. Which diet modification would be the best choice for the client? A. Pureed B. Mechanically altered c. Full liquids D. Clear liquids

The nurse is caring for a client who had abdominal surgery yesterday and is reluctant to cough and perform deep breathing. Which strategy will most likely increase the client's willingness to cough and perform deep breathing? A. Teach the client how to splint the abdomen while coughing. B. Assist the client to a side-lying position to cough. C. Administer respiratory treatments to encourage coughing. D. Remind the client of the serious complications that can result from ineffective coughing and deep breathing.

The nurse is caring for a client with an enlarged thyroid gland. Which nutritional deficiency will the nurse suspect is linked to the client's condition? A. Iodine B. Magnesium C. Sodium D. Potassium

The nurse is educating a new colostomy client on gas-producing foods. Which food is a gas-producing food the client may choose to avoid? A. brussels sprouts B. rice C. green peppers D. lettuce

The nurse is preparing a client to receive a hypertonic enema solution. Into which position will the nurse place the client? A. Sims B. semi-Fowler's C. prone D. supine

The nurse is providing care to several clients. For which client should the nurse include secondary care in the nursing plan of care? A. A middle-aged client who presents with new-onset angina B. An adolescent client who requires a sports physical C. An older adult client who requires a medication refill D. A pediatric client who tests positive for strep

The nurse is supervising a nursing student who is providing postoperative education to a client with an abdominal incision. The nurse sees the student coaching the client to perform coughing exercises, as pictured above. What is the nurse's best action? A. Instruct the student to provide the client with a pillow or folded blanket to hug. B. Help the client determine whether she is able to dangle at the side of the bed. C. Remind the student to support the client while she performs the exercises. D. Help the student assist the client into a high Fowler's position.

The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate? A. "Dehiscence is when a wound has partial or total separation of the wound layers." B. "Dehiscence is not anything that you need to worry about." C. "Dehiscence is a total separation of the wound with protrusion of the viscera through it." D. "Dehiscence is the softening of tissue due to excessive moisture."

The nurse is talking with a client who wishes to have a tattoo removed. Which client statement indicates that the client understands how the procedure will be accomplished? A. "The provider will perform this laser surgery in an ambulatory care setting." B. "I will talk with the anesthesiologist about anesthesia." C. "This inpatient surgical procedure requires me to be at the hospital the morning of surgery." D. "I will plan to be hospitalized several days following the procedure."

The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include? A. "Very little scar tissue will form." B. "This is a complex reparative process." C. "The margins of your wound are not in direct contact." D. "The surgeon will leave your wound open intentionally for a period of time."

The nurse is teaching an 80-year-old client how to instill eye drops for glaucoma. The client's daughter asks, "How do you know that my mother understands what to do?" What is the appropriate nursing response? A. "When 15 minutes have passed, I will ask your mother to show me how to instill the drops." B. "After I demonstrate it once, your mother will be able to do it." C. "We can never be completely sure that your mother understands instructions." D. "I will have you bring your mother back next week to see how things are going."

The nurse is teaching four clients in a community health center. Which client does the nurse identify as needing more servings per day of milk? A. teenager who is in the second trimester of pregnancy B. middle-age male who works night shift C. new mother who is bottle-feeding a baby D. older adult who lives with grown children

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

The nurse understands that a diagnostic-related group is one of the reimbursement strategies in a prospective payment system. The diagnostic-related group is a part of which health care system? A. Medicare B. Medicaid C. Capitation D. AmeriCare

The nurse understands that planning for discharge actually begins at admission to the facility. The purpose of discharge planning is best described as: A. providing continuity of care that is goal directed. B. decreasing stress for client and family members. C. ensuring client safety and health maintenance. D. promoting less dependence on others.

The nursing instructor is discussing alternative therapy with a group of students. She explains that living organisms are "continuously connecting and interacting with their environment." Furthermore, the connecting and interacting signifies that the human body is a unified dynamic whole. The instructor is describing what theory to the students? A. Holism perspective B. Allopathic perspective C. Integrative perspective D. Medical system perspective

The nursing process is based upon the process of problem solving. The nurse attempts to obtain a blood pressure on the client's right arm, then on the left arm, then on the left leg, and finally on the right leg, where the blood pressure is obtained. What type of problem solving did the nurse use? A. Trial-and-error problem solving B. Critical thinking C. Intuitive thinking D. Scientific problem solving

The preoperative nurse has prepared a client for surgery and has been notified that the operating room staff is ready for the client. The client states, "My bladder feels full. I need to go to the bathroom!" Which action by the nurse is appropriate? A. Inform the operating room staff and assist the client to the bathroom. B. Insert a catheter into the bladder. C. Remind the client that bladder fullness is a common preoperative sensation. D. Inform the client that anesthesia will prevent the bladder from emptying during surgery.

The type of intervention that the nurse performs when he or she observes the spouse of a postoperative client performing the client's dressing change is described as A. Supervisory B. Maintenance C. Surveillance D. Technical

Two new nurses are requesting the same preceptor for unit orientation. Both new nurses have been very vocal about being unhappy if they do not receive their choice of preceptor. Which illustrates the nurses using a compromise approach to conflict resolution? A. The nurses agree to have the preceptor precept one nurse at the beginning of the orientation and the other at the end. B. The nurses ignore each other's request for the preceptor. C. The nurses agree that one nurse will obtain the preceptor for orientation in exchange for that nurse working each weekend. D. The nurses agree to allow the preceptor to decide which nurse to precept.

What is an appropriate intervention when unexpected situations occur during the administration of a tube feeding? A. If the tube becomes clogged when aspirating contents, use warm water and gentle pressure to remove the clog. B. If the client complains of nausea after tube feeding, lower the head of the bed and administer an antiemetic. C. If the tube is found to be in the stomach instead of the esophagus, follow the recommended steps to replace the tube. D. When checking for residue, if a large amount is aspirated, replace the residue before proceeding with feeding.

What is the most appropriate teaching strategy for the nurse to use for a 1-hour presentation on the prevention of osteoporosis to a group of 30 college-age women? A. Lecture/discussion B. Role play C. Demonstration D. Test taking

What is the priority nursing responsibility when transferring a client from one unit in the hospital to another? A.Provide a verbal report of the client's status to the admitting nurse. B. Help the client become familiar with the new unit. C. Bring all of the client's belongings to the new unit. D. Transport the completed client chart to the receiving unit.

When caring for a client with a new colostomy, which assessment finding would be considered abnormal and would need to be reported to the physician? A. The stoma is prolapsed. B. The stoma is on the abdominal surface. C. The stoma is pink. D. The stoma has a small amount of bleeding.

When communicating with an employee, the nurse manager must: A. communicate congruently. B. be agreeable. C. be aware of surroundings. D. reserve time to be attentive.

When conducting an education program for a group preparing for retirement, the nurse would include information about applying for Social Security benefits and Medicare insurance. The nurse would include in the education that Medicare is a federally funded insurance program which bases the fee for payment on what? A. A prospective payment plan based on a predetermined fixed cost B. The need to cut health care costs for indigent older adults C. A payment to physician groups willing to take Medicare clients D. A retrospective payment plan, after the service is rendered

When talking with family over dinner, the nurse shares about a client with infertility at the hospital, identifying the person by name. Which tort has the nurse committed? A. Invasion of privacy B. Assault C. Slander D. Fraud

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

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

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

Which nursing action is performed according to guidelines for aspirating fluid from a small-bore feeding tube? A. If fluid is obtained when aspirating, measure its volume and pH and flush the tube with water. B. Use a small syringe and insert 10 mL of air. C. Continue to instill air until fluid is aspirated. D. Place the client in the Trendelenburg position to facilitate the fluid aspiration process.

Which nursing student statement regarding vegetarian diets requires further teaching from the nursing instructor? A. "According to research, vegetarians have a higher incidence of obesity than others." B. "Semi-vegetarians exclude red meat from their diet and seek protein elsewhere." C. "Colorectal cancer is not as common in vegetarians compared to people who eat high fat diets." D. "Protein complementation is important to help the client get the needed amino acids."

Which of the following has been known to achieve benefits for clients with cancer through the use of the mind to visualize a positive physiologic effect? A. Imagery B. Biofeedback C. Humor D. Hypnosis

Which scenario is an example of certification? A. A nurse who demonstrates advanced expertise in a content area of nursing through special testing B. A graduate of a nursing education program who passes the NCLEX-RN C. A hospital that meets the standards of the Joint Commission D. An education program that meets the standards of the National League for Nursing

Which scenario is using a prospective payment plan to reimburse for services? A. An older adult client is admitted to the hospital and treated for pneumonia. The hospital is reimbursed based on a predetermined fixed price. B. A client with chronic heart failure is offered health care teaching and preventative services for free. C. A child is hospitalized and treated for a fractured femur. The hospital receives a preset fee for each member regardless of whether the member required services. D. A client is hospitalized for an emergency appendectomy. Since the hospital is a preferred provider the fee for service was discounted.

Which symptom is a known side effect of antibiotics? A. Diarrhea B. Fecal impaction C. Abdominal bloating D. Constipation

Which would be the least consistent with the Native American/Canadian Indigenous view of disease? A. Balance of yin and yang B. A result of negative thinking C. Disharmony with Mother Earth D. Violation of a taboo

While a client admitted to the medical-surgical unit is in the radiology department, a visitor claiming to be the client's cousin arrives on the medical-surgical unit and asks the nurse to provide a brief outline of the client's illness. Which response by the nurse would be most appropriate, both legally and professionally? A. "I cannot give you that information due to client confidentiality." B. "I will call the client and ask for permission to share this infomation with you." C. "Do you have any identification proving that you are related to the client?" D. "I'm busy right now but can talk later."

he nurse is working to enhance time management skills and has to administer pain medications to several patients, obtain vital signs, and assist clients with bathing. What should the nurse do next? A. Delegate bathing and vital signs tasks. B. Administer pain medications. C. Obtain vital signs. D. Bathe clients.

Which are ethical issues that need to be considered as health care reform continues? Select all that apply. A. Is someone who can afford to advertise for an organ donation more deserving than someone who has been waiting months for a transplant? B. Should citizens pay higher insurance premiums and/or taxes so that someone who overdoses on heroin can have intensive care? C. Do smokers and the obese who do not make necessary lifestyle changes deserve the same health care as people who lead healthier lives? D. Should undocumented peoples in the U.S. have the same access to health care as its citizens? E. Should hospitals and providers receive payment from health insurance entities based in part on patient satisfaction scores?

A, B, C, D

Which are ethical issues that need to be considered as health care reform continues? Select all that apply. A. Do smokers and the obese who do not make necessary lifestyle changes deserve the same health care as people who lead healthier lives? B. Is someone who can afford to advertise for an organ donation more deserving than someone who has been waiting months for a transplant? C. Should undocumented peoples in the U.S. have the same access to health care as its citizens? D. Should hospitals and providers receive payment from health insurance entities based in part on patient satisfaction scores? E.Should citizens pay higher insurance premiums and/or taxes so that someone who overdoses on heroin can have intensive care?

A, B, C, E

A client with no significant medical history reports experiencing diarrhea over the past week. Which assessment question will the nurse ask? Select all that apply. A. "What are your normal bowel habits?" B. "Have you started a new medication?" C. "Are you experiencing rectal fullness?" D. "Do you use laxatives?" E. "Is the stool difficult to pass?"

A, B, D

A nurse is using the teaching-learning process to teach new parents how to care for their infants. Which nursing actions reflect recommended steps of this process? Select all that apply. A. The nurse formulates a verbal or written contract with clients. B. The nurse relates new learning material to clients' past life experiences to help them to assimilate new knowledge. C. The nurse includes group teaching and formal teaching in every education plan. D. The nurse assesses the learning needs and readiness of the parents. E. The nurse does not allow time constraints, schedules, and the physical environment to influence the choice of education strategies. F. The nurse identifies general long-term goals for client learning when developing learning objectives.

A, B, D

A client comes to the clinic for a routine visit. During the interview, the client tells the nurse, "I'd really like to try to use some herbs and supplements to stay healthy. Do you have any suggestions for what I should do?" Which response by the nurse would be appropriate? Select all that apply. A. "Make sure to understand what you are taking and the reason why." B. "Use products from reputable companies that have tested their quality." C. "The label lists the minimum you should take, so doubling up would be okay." D. "Learn about the product you are planning to use." E. "Try using products that are combinations of several ingredients."

A, B, D, E

An older adult client is recovering from hip replacement surgery and scheduled for discharge in 2 days. According to the Health Belief Model, which factors would be important to assess before the client goes home? Select all that apply. A. if the client feels safe in the home B. the living environment C. what others have heard about recovery from the procedure D. expectations for recovery E. how recovery has been from previous procedures

A, B, D, E

A nurse is admitting a client to a hospital. Which actions should the nurse perform initially upon this admission? Select all that apply. A. The nurse asks the client about existing advance directives; if none, the nurse gives the appropriate form to the client. B. The nurse obtains client information, which is printed on an admission sheet and becomes part of the client's permanent record. C. The nurse makes sure the client's name and address and the name of the closest relative are printed on an identification bracelet. D. The nurse asks the client to sign consent forms allowing treatment and the hospital to contact insurance companies as needed. E. The nurse clearly describes how the client information will be used and disclosed to other parties. F. The nurse gives the client a form explaining the Patient Care Partnership.

A, B, D, E, F

In prenatal classes, the nurse teaches pregnant clients to use meditation during labor contractions to ease the pain. Which elements of meditation are important for the nurse to emphasize? Select all that apply. A. Quiet environment B. Closed attitude C. Focus of attention D. Comfortable position E. Massaging abdomen

A, C, D

Which statements are true about the implementation phase of the nursing process? Select all that apply. A. Care provided during implementation should be documented in the client's chart. B. Implementation is only carried out by nursing professionals. C. Implementation is the process of carrying out the plan of care. D. This phase promotes wellness and restores health. E. All interventions carried out during this phase must be accompanied by a physician's order.

A, C, D

The nurse is caring for a client with an irregular-shaped traumatic wound. What principles should the nurse use when gathering information about the wound to chart? Select all that apply. A. Draw the shape of the wound with a description. B. Use a dry sterile applicator at a 90-degree angle to measure depth. C. Assess color, drainage, presence of pain, or complications. D. Chart tunneling by using a quadrant approach to describe the location. E. Measure the wound's length and width.

A, C, E

The nurse is educating a client on how to use herbs and supplements as part of an integrated treatment plan. Which teaching points would the nurse include? Select all that apply. A. Buy herbs and supplements that are standardized. B. Whenever possible, buy products with more than one ingredient. C. Use the Internet to buy herbs and supplements. D. Give the product adequate time to work. E. Be knowledgeable about the product and its therapeutic actions. F. Take a higher than recommended dose of herbs to initiate the therapeutic effect.

A, D, E

When developing a nursing plan of care and associated client outcomes, what should the nurse recognize? Select all that apply. A. Outcomes can be short- and long-term. B. All plans of care are the same for clients with certain medical diagnoses. C. Only the client is involved in outcome setting, not the family. D. Outcome setting allows for individualization of the plan of care. E. A plan of care should be comprehensive and ongoing, covering and being updated during all phases of care.

A, D, E

What information must be provided to a client to obtain informed consent? Select all that apply. A. A description of the procedure or treatment, along with potential alternative therapies B. Explanation that a signed consent form is binding and cannot be withdrawn C. The name and qualifications of the nurse providing perioperative care D. Customary insurance coverage for the procedure E. The underlying disease process and its natural course F. Explanation of the risks involved and how often they occur

A, E, F

A nurse practitioner is conducting a presentation at a local community center about complementary health approaches. One of the participants asks the nurse practitioner, "Everybody is talking about relaxation. Just how does relaxation help a person?" The nurse responds, integrating which effect as being associated with relaxation? Select all that apply. A. Reduced muscle tension B. Better sleep and rest C. Lowered immune response D. Less anxiety E. Improved sense of well-being

A,B,D,E

On the advice of friends, a client on a palliative care unit has requested acupuncture. What it is the goal of this form of CAM? A. restoring a healthy flow of energy along the meridians of the body B. allowing accumulated toxins to be released from the body C. reconnecting the client's body, spirit, and emotions D. altering the client's perception and acceptance of reality

A Chinese client who was previously treated at the health care facility for an open wound has been admitted again because the wound has become gangrenous. It has been identified that the client failed to understand proper wound care. What is the probable reason for the client failing to understand the instruction? A. The client has a short attention span. B. The client belongs to a different culture. C. The client is a passive learner. D. The client is not interested.

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon. A. False B. True

A client asks a nurse about the benefit of using diagnosis-related groups (DRGs) as a reimbursement method. Which is the nurse's best response? A. "DRGs are an inefficient way for the government to manage a client's hospital recovery." B. "DRGs have helped to reduce healthcare costs by decreasing the overall length of a client's hospital stay." C. "This innovative cost-cutting approach has led to a decrease in hospital admission rates." D. "This reimbursement method focuses on preventing illness through screening and health promotion."

A client asks about whether to consult a naturopathic physician for treatment. Which client factor would the nurse consider in determining the client would benefit from this consult? A. The client is eating vegetables grown from a garden at home. B. The client states "I spend a lot of time watching television." C. The client reports sleeping 7-8 hours a night. D. The client states "I am generally an optimist."

A client had an open cholecystectomy (gallbladder removal) 36 hours earlier, and the nurse's assessment this morning confirms that the client has not yet had a bowel movement since prior to surgery. How should the nurse best respond to this assessment finding? A. Immediately administer a cleansing enema. B. Monitor the client closely and promote fluid intake. C. Increase the rate of the client's intravenous infusion. D. Contact the physician to come assess the client.

A client has a history of long-term alcohol use. Which nutrient would need to be required in increased amounts? A. Vitamin C B. Vitamin B C. Calcium D. Thiamin

A client has had major abdominal surgery and just returned to the unit from the operating room. The nursing priority is to: A. evaluate the abdominal dressing for drainage. B. complete the postoperative assessment. C. administer pain medication. D. expect the client to be drowsy, and let the client rest.

A client reports weakness following administration of insulin. The nurse decides to assess the client's blood glucose level and prepare a snack in case the level is low. Which action has the nurse implemented? A. Assessment B. Clinical reasoning C. Caring D. Reflection

A female client tells the nurse, "I try to consume 2000 calories daily by eating a variety of proteins, carbohydrates, and fats." What is the appropriate nursing response? A. "You are eating too many calories for an adult woman." B. "That is a healthy amount of daily caloric intake." C. "Your diet should be richer in nutrients, vitamins, and minerals." D. "It doesn't matter which foods you eat, as long as you consume 2000 calories daily."

A nurse administers medications to a client. Which step of the nursing process would the nurse perform next? A. Planning B. Evaluating C. Assessing D. Diagnosing

A nurse assisting a new mother in the act of breastfeeding represents which form of learning? A. Affective B. Psychomotor C. Simplistic D. Cognitive

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

A nurse identifies the following: "The client will report a pain rating of 4 or less within 30 to 45 minutes of receiving prescribed analgesic." The nurse has identified: A. intervention. B. outcome. C. subjective data. D. nursing diagnosis.

A nurse informs the client that the client has no choice and must take a bath in the morning. What type of leadership does this exemplify? A. Institutional governance B. Directive leadership C. Shared governance D. Participative leadership

A nurse is attempting to complete an admission database. While taking the history, the nurse notices the client appears uncomfortable and slightly tachypneic. The nurse should: A. tell the client to rest and allow a family member to answer. B. allow the client to set the pace. C. use only open-ended questions. D. ask questions as quickly as possible.

A nurse is caring for a client who has been ordered a clear liquid diet. Which liquid can be included in the client's diet? A. Tomato soup B. Cranberry juice C. Orange juice D. Low-fat milk

A nurse is caring for a client who is newly diagnosed with terminal cancer. The nurse enters the client's room and finds the client sitting in the dark crying. Which statement conveys empathy by the nurse? A. "Sitting in the dark is not going to cure your cancer. Let's open the curtains." B. "I know this is hard for you. Is there any way I can help?" C. "I am so sorry you are going through this. Can we talk?" D. "Can you please tell me why you are crying?"

A nurse is caring for a client whose primary care provider has written an order for "enemas until clear." Which explanation to the client about this procedure is correct? A. "This enema will assist in your bowel regimen when you go home." B. "I will administer enemas until the enema return is without stool." C. "I will administer up to three enemas as prescribed." D. "You will need to have enemas unless you can consume clear liquids without nausea."

A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site? A. hydrocolloid B. transparent C. gauze D. bandage

A nurse is caring for a postoperative client 1 day after a total abdominal hysterectomy. Which nursing intervention best demonstrates caring in this situation? A. Assessing the abdominal incision B. Assisting the client to sit up in a chair C. Notifying the health care provider of lab results D. Monitoring vital signs

A nurse is caring for an older adult following hip surgery. When teaching the client to use an incentive spirometer, the nurse should explain that this reduces the risk of what complication? A. Asthma B. Pneumonia C. DVT D. Bronchitis

A nurse is discharging a client and thus terminating the nurse-client relationship. Which action should the nurse perform in this phase? A. Make formal introductions B. Examine goals of the relationship to determine whether they were achieved C. Create a contract regarding the relationship D. Provide assistance to achieve goals

A nurse is educating a 4-year-old client about cast care following a tibia-fibula fracture. Which action is not developmentally appropriate to include in the nurse's teaching? A. Using dolls to demonstrate psychomotor skills B. Blocking 30 minutes of time for skill teaching C. Giving stickers as a reward for task completion D. Ensuring the client's parents are present

A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn? A. Superficial, which may be pinkish or red with no blistering B. Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown C. A superficial partial-thickness burn, which can appear dry and leathery D. May vary from brown or black to cherry red or pearly white; bullae may be present

A nurse is obtaining a history from an adult female client. When the nurse asks how many times the client has been pregnant, the client answers, "I have four kids." Which statement, made by the nurse, seeks clarification of the original question? A. "All right, you have four children, is that correct?" B. "I understand you have four kids; how many times have you actually been pregnant?" C. "Were these term births?" D. "How old are your children?"

A nurse is preparing to teach a 6-year-old client with a broken arm and the client's mother about caring for the child's cast. Which statement reflects the best education plan for these clients? A. Provide the mother with written materials; teach the child about keeping the cast dry. B. Include the child in the education; ask questions of both the mother and the child. C. Focus mainly on the mother; ask the child a couple of simple questions. D. Separate the mother and the child; teach the mother and then let the mother teach the child.

A nurse is providing care to a client who has come to the outclient clinic for chemotherapy. The client tells the nurse that to cope with the stress of chemotherapy, he uses a technique in which he "goes to my happy place, the beach, and I picture myself lying there under the warm sun, with the sound of the waves lapping at the shore." The nurse interprets this as which technique? A. Tai chi B. Guided imagery C. Meditation D. Yoga

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

A nurse is working with a 15-year-old client with sickle cell anemia. The client was started on a new pain management plan today, and the nurse is evaluating the effectiveness of the plan. Which is not appropriate to include in the nursing care? A. Including a note about who was taught this new information in the client's chart B. Asking only the client's parents to be present at the education session C. Answering questions openly and honestly D. Assuring the client that the conversation is confidential except under extreme circumstances

A nurse is working with an older adult client, educating the client on how to ambulate with the aid of a walker. The nurse notes that the client appears to lack the motivation to learn how to use the device. The client states, "I'm just too old to learn." What would be most appropriate for the nurse to do to motivate this client? A. Tell the client how to move the walker as the client ambulates. B. Describe how the walker can improve the client's quality of life. C. Explain how the walker supports the client's lower extremities. D. Fully discuss the rationale for using the walker.

A nurse manager best demonstrates effective leadership characteristic by which action? A. Knowing all information about the unit processes B. Sharing a vision for the unit and enlisting support C. Being very structured and rigid with the unit flow D. Indicating an interest in becoming a role model

A nurse technician is assigned to take clients' vital signs. When making rounds, the nurse notices that one client's vital signs are very different from what they were at the beginning of the shift. What is most appropriate for the nurse to do about these findings? A. Call the health care practitioner for new orders. B. Assess the client's vital signs again. C. Document the vital signs in the client's chart. D. Ask the nurse technician whether the vital signs are correct.

A nurse who has been caring for a client for the past few days is preparing the client for discharge and termination of the nurse-client relationship. Which activity would the nurse be carrying out during this phase of the relationship? A. Attending to physical health care needs B. Reviewing health changes C. Developing solutions that will be enacted D. Establishing trust and rapport

A nurse witnesses a traffic accident and dresses the open wounds sustained by a child. Later, in the hospital, the child develops complications from an infection in the wound. The family holds the nurse responsible for the complications and attempts to file a lawsuit. Which statement is true regarding how the Good Samaritan law applies to this case? A. The Good Samaritan law will provide absolute exemption from prosecution. B. The Good Samaritan law will provide legal immunity to the nurse. C. The Good Samaritan law is not applicable to health care workers. D. The Good Samaritan law will not protect the nurse because the nurse did not accept compensation.

A nurse, while off-duty, tells the physiotherapist that a client who was admitted to the nursing unit contracted AIDS due to exposure to sex workers at the age of 18. The client discovers that the nurse has revealed the information to the physiotherapist. With what legal action could the nurse be charged? A. Libel B. Slander C. Malpractice D. Negligence

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child? A. In children younger than 2 years, the skin is thicker and stronger than in adults. B. An infant's skin and mucous membranes are easily injured and at risk for infection. C. An individual's skin changes little over the life span. D. A child's skin becomes less resistant to injury and infection as the child grows.

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. Total parenteral nutrition (TPN) C. Percutaneous endoscopic gastrostomy tube (PEG) D. Partial or peripheral parenteral nutrition (PPN)

A postmenopausal client wishes to increase the amount of vitamin D that she consumes to help keep her bones strong. Which food will the nurse recommend? A. green leafy vegetables B. milk C. whole-grain cereal D. red meat

A successful discharge includes effective planning. Identifying and meeting client needs beyond the acute care facility reduce readmissions. Which nursing role is of great importance to this success? A. Nurse practitioner B. Coordinator C. Caregiver D. Clinician

After a nurse manager implements a solution to the problem of delays in obtaining supplies, the first task for the manager is to: A. plan to monitor the supply cabinets. B. assess whether the desired results have occurred. C. ask the staff members for other solutions. D. make an appointment with the chief nursing officer.

An adolescent client is being taught about changing an abdominal dressing as part of the education for care at home. On removing the dressing and seeing the surgical incision, the client becomes tearful. What knowledge deficit is best to address for this client at this moment? A. Pain related to surgical incision B. Altered body image related to surgical incision C. Infection related to surgical incision D. Self-care deficit secondary to surgical incision

An athlete wants to increase the intake of complex carbohydrates and asks the nurse about potential sources. Which food is considered a complex carbohydrate? A. Eggs B. Pasta C. Honey D. Peanuts

An older adult client who is recovering from a stroke is scheduled to be transferred to the rehabilitation unit in the morning. The client is tearful and reports feeling lonely and abandoned in the hospital unit. The family visits daily, and flowers and cards are in the room. Documentation in the chart indicates that the client's pastor has been by twice in the past week to visit. Which nursing diagnosis and outcome criteria need to be addressed immediately for this client? A. Altered Mobility; able to tie shoes. B. Ineffective Coping; verbalizes support systems. C. Dysfunctional Family Processes; family contact daily. D. Impaired Walking; unilateral neglect.

Based on the Patient Protection and Affordable Care Act (ACA), nurses are to assume an important new role in health care. Which is an example of this new role? A. Identifying individuals who are at risk of developing diabetes mellitus B. Collaborating with all agencies to provide for the client's home health needs C. Providing client education related to colostomy care D. Verifying that all documentation is updated prior to surgery

Educating a client on the pathophysiology of diabetes mellitus is the implementation of which skill? A. Technical B. Intellectual C. Visual D. Interpersonal

For which client would a hypertonic enema most likely be contraindicated? A. A client who is severely constipated B. A client with renal impairment C. A client with type 1 diabetes D. A client who has peripheral edema

In a nursing unit, the RN delegates nursing tasks to the nursing assistant. Keeping in mind the delegation guidelines, which statement denotes the right communication for the nursing assistant? A. "Discontinue the IV solution." B. "Dispose of the disconnected IV set." C. "Check the infusion rate." D. "Inspect the site for thrombophlebitis."

In anticipation of discharge, a nurse is teaching the daughter of an older adult client how to change the dressing on the client's venous ulcer. Which teaching strategy is most likely to be effective? A. Use a multimedia strategy that combines animation with narration. B. Demonstrate and explain the procedure and then have the daughter perform it. C. Explain the procedure clearly and slowly while providing multiple opportunities for the daughter to ask questions. D. Provide explicit written and verbal instructions and ask the daughter to explain back to the nurse how to perform the procedure.

Nurses in various health care settings provide services to prevent the fragmentation of care that is occurring as a health care trend in today's society. What role of the nurse is most important in preventing this effect? A. Counselor B. Coordinator of care C. Educator D. Care provider

Nurses in various health care settings provide services to prevent the fragmentation of care that is occurring as a health care trend in today's society. What role of the nurse is most important in preventing this effect? A. Educator B. Coordinator of care C. Care provider Counselor

On a particular 12-hour day shift, the nurse-client ratio on a busy floor is lower than usual because a member of the health care team called in sick for the day. Which example shows this nurse practicing with a good sense of legal competence in response to this challenge? A. Instead of documenting every 2 hours per hospital protocol, the nurse documents a detailed shift assessment and an end-of-shift note to cover what has happened during the shift. B. Following the chain of command, the nurse requests help completing the tasks essential to client care that day. C. The nurse leaves some tasks that cannot be completed during the day shift for the night shift, including the 4 pm labs. D. To save time, the nurse asks an experienced coworker what the safe dosage of a medication for a client would be rather than look it up.

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. "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention." B. "Your wound will heal slowly as granulation tissue forms and fills the wound." C. "As soon as the infection clears, your surgeon will staple the wound closed." D. "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal."

The charge nurse on the orthopedic unit believes in giving the staff as much power as possible. The nurses are allowed, among other things, to create their own work schedules, provide dates and times for unit meetings, and create the agendas, to which the charge nurse contributes. The charge nurse's style of leadership can be described as which? A. Autocratic B. Laissez-faire C. Democratic D. Transformational

The client has been diagnosed with a disease and is seeking information about naturopathy. The nurse, explaining about naturopathy, encourages the client to do what? A. Include well-cooked processed foods in diet. B. Obtain adequate sleep each night. C. Exercise at least once per week. D.Concentrate on the implications of the disease.

The healthy adult client is given a narcotic prior to a surgical procedure. The nurse is completing the chart and notices the consent form was not signed by the client. Which of the following should the nurse do first? A. Ask the client if he still wants to proceed with the procedure. B. Notify the physician of the oversight. C. Have the client's family member sign the consent form. D. Immediately have the client sign the consent form.

The nurse has been waiting until after the administration of a toddler's anesthesia before removing the child's clothing and applying monitoring equipment. Doing these actions after the administration of anesthesia will: A. enhance thermoregulation. B. prevent anxiety. C. minimize blood loss. D. provide more accurate baseline vital signs.

The nurse has measured from the tip of the client's nose to the earlobe and then down to the xiphoid process before inserting a nasogastric (NG) tube and attaching it to low suction. Which components of the nursing process has the nurse demonstrated? A. Implementing; evaluation B. Planning; implementing C. Diagnosing; implementing D.Assessing; diagnosing

The nurse is a member of the multidisciplinary team in a large primary healthcare setting. The nurse understands that which healthcare team member is responsible for a client's swallow evaluation following a cerebral vascular accident? A. Physical therapist B. Speech pathologist/therapist C. Physician assistant D. Occupational therapist

The nurse is admitting a client for outpatient surgery. When the nurse asks what the client has been told about self-care following discharge, the client says, "No one has told me anything." Which nursing intervention is indicated? A. Advise the client to delay the surgery. B. Provide the teaching. C. Alert the charge nurse in surgery. D. Notify the surgeon.

The nurse is caring for a 70-year-old client with a fractured wrist. Which is the best method to determine whether the client has retained the information taught? A. Test the client on the health education and information imparted. B. Ask the client to recall after approximately 15 minutes. C. Observe the change in client's behavior for a month. D. Ask the client to administer the doses of drug himself.

The nurse is caring for a client receiving continuous tube feeding. The client has a gastric residual of 550 mL. The previous residual was 200 mL. What action should the nurse take? A. Call the primary care provider for a promotility agent. B. Hold the enteral nutrition and notify the primary care provider. C. Discard the residual, chart the amount, and continue the tube feeding. D. Replace the residual, chart the amount, and continue the tube feeding.

The nurse is caring for a client with a nursing diagnosis of deficient fluid volume. The nurse has implemented the plan of care and on evaluation finds that the client continues to exhibit symptoms of deficient fluid volume. What should the nurse do next? A. Develop an additional nursing diagnosis to meet the client's health needs. B. Modify the plan of care and interventions to meet the client's needs. C. Reassess the client for more symptoms of deficient fluid volume. D. Change the nursing diagnosis because the client's problem was falsely identified.

The nurse is caring for an obese client who needs to be turned every 2 hours. Which action by this nurse is an example of reflection-for-action? A. After turning the client alone, the nurse realizes that the nurse should have insisted on having help. B. Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care. C. During the first attempt to turn the client, the nurse realizes the need for assistance and calls the front desk for help. D. The nurse decides to turn the client every 4 hours because everyone is too busy to help.

The nurse is performing a nutritional assessment of an obese client who visits a weight control clinic. What information should the nurse take into consideration when planning a weight reduction plan for this client? A. Obesity is very treatable, and 50% of obese people who lose weight maintain the weight loss for 7 years. B. Psychological reasons for overeating should be explored, such as eating as a release for boredom. C. To lose 1 pound/week, the daily intake should be decreased by 200 calories. D. One pound of body fat equals approximately 5,000 calories.

The nurse is performing an admission interview with a new client diagnosed with acute coronary syndrome. For the nurse to obtain information and allow the client free verbalization, which question would elicit the most information? A. "I have had chest pain before, and it is really scary!" B. "Could you tell me more about how you are feeling right now?" C. "Have you ever had chest pain prior to this admission?" D. "Did you take any medication when you had the pain?"

The nurse is performing an assessment on a client who reports having a rash on the back that is red and raised. What would be the most appropriate nursing action? A. Document the rash in the client's chart. B. Assess the client's back visually. C. Report it to the health care provider. D. Establish a nursing diagnosis of Altered Skin Integrity.

The nurse is providing education to a client with high triglyceride and cholesterol levels. Which food should the client be cautioned to avoid? A. chicken B. coconut C. fish D. sunflower

The nurse is providing instructions to a client about performance of breast self-examination. What learning outcome would be most appropriate regarding this education? A. The client will have restoration of breast function. B. The client will be able to perform proper breast self-examination for breast cancer detection and prevention. C. The client will demonstrate self-efficacy and improved body image. d. The client will demonstrate improved coping skills.

The nurse is scheduling tests for a client who is experiencing bowel alterations. What is the most logical sequence of tests to ensure an accurate diagnosis? A. endoscopic examination, barium studies, fecal occult blood test B. fecal occult blood test, barium studies, endoscopic examination C. barium studies, endoscopic examination, fecal occult blood test D. barium studies, fecal occult blood test, endoscopic examination

The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include? A. "The surgeon will leave your wound open intentionally for a period of time." B. "Very little scar tissue will form." C. "This is a complex reparative process." D. "The margins of your wound are not in direct contact."

The nurse is teaching a client about wound care at home following a cesarean birth of her baby. Which client statement requires further nursing teaching? A. "I will not remove the staples myself." B. "Reinforced adhesive skin closures will hold my wound together until it heals." C. "After delivery, I will have sutures in place." D. "I may have staples in place for a number of days."

The nurse is teaching a client with rectal bleeding about fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide? A. "This test will show if you have an infection in the bowel." B. "This test detects heme, a type of iron compound in blood in the stool." C. "This test will determine whether foods are contributing to rectal bleeding." D. "This test will show if you have colorectal cancer."

The nurse manager who asks staff members to give suggestions on how to improve collaboration between nurses and physicians is exhibiting what style of leadership? A. Transactional B. Democratic C. Autocratic D. Laissez-faire

The nurse performs gastrostomy site care and notes drainage. What action does the nurse take? A. Clean the site with hydrogen peroxide. B. Place a drain sponge under the external bumper. C. Administer an antibiotic ointment to the site. D. Notify the health care provider.

The parents of a school-age child are meeting with the nurse for health promotional education for their child. The child has the following assessment data: a 7-year-old male with diabetes mellitus type 1 with a hemoglobin A1C level of 8.3%, a body mass index (BMI) of 31.7, and a BMI percentile of 99. What are the most appropriate learning diagnoses for this first session? A. Deficient Knowledge: Risk for imbalanced nutrition: more than body requirements, and sedentary lifestyle. B. Deficient Knowledge: Imbalanced nutrition: more than body requirements, and ineffective health maintenance. C. Deficient Knowledge: Readiness for enhanced nutrition, and risk for disturbed body image. D. Deficient Knowledge: Risk for chronic low self esteem, and risk for unstable blood glucose level.

The recovery nurse is caring for a surgical client in the PACU. The client's blood pressure is dropping and the heart rate is increasing. The nurse suspects the client is: A. experiencing normal adaptation to the postoperative period. B. developing shock. C. overmedicated. D. allergic to the anesthesia.

The student nurse is administering a large-volume enema to a client. The client reports abdominal cramping. What should the student nurse do first? A. Stop the administration of the enema and notify the physician. B. Stop the administration of the enema momentarily. C. Increase the flow of the enema for approximately 30 seconds then decrease it to the prior flow rate. D. Increase the flow of the enema until all of the solution has been administered.

When communicating with clients, nurses need to be very careful in their approach. This is particularly true when communicating using: A. written material. B. medical terminology. C. audio-visual material. D. demonstration.

When conducting an education program for a group preparing for retirement, the nurse would include information about applying for Social Security benefits and Medicare insurance. The nurse would include in the education that Medicare is a federally funded insurance program which bases the fee for payment on what? A. The need to cut health care costs for indigent older adults B. A prospective payment plan based on a predetermined fixed cost C. A retrospective payment plan, after the service is rendered D. A payment to physician groups willing to take Medicare clients

When educating an older adult client on the prevention of constipation, the nurse should provide which educational intervention? A. Eat 6 servings of bread or pasta. B. Increase intake of fresh vegetables. C. Consume antacids to decrease reflux. D. Drink 3 glasses of milk per day.

When establishing a teaching-learning relationship with a client, it is most important for the nurse to remember that effective learning can best be achieved through which concept? A. Assimilation and application of psychomotor concepts is essential. B. The client and the nurse are equal participants. C. The nurse is the expert in the teaching-learning environment. D. The nurse must be able to handle criticism during the process.

When preparing to transfer an older adult client back to the long-term care facility where the client has been for several years, it is the primary responsibility of the nurse to: A. communicate to the next of kin so they are aware of the transfer. B. provide for the coordination and continuity of care by the health care providers. C. discuss the return to familiar surroundings with the client. D. ensure that the current health state of the client is maintained.

Which guideline is most important for the nurse to keep in mind when planning to teach an exercise class to a group of older adults? A. Allow for long-term memory loss. B. Allow ample time for psychomotor skills. C. Provide information in a structured format. D. Keep the session at 2 to 3 hours.

Which intervention is most appropriate for a client newly diagnosed with diabetes and a nursing diagnosis of Deficient Knowledge? A. Monitor for hypoglycemia and hyperglycemia. B. Teach the client how to administer insulin. C. Monitor blood glucose level before meals. D. Administer insulin as prescribed.

Which is not considered a skin appendage? A. Eccrine sweat glands B. Connective tissue C. Hair D. Sebaceous gland

Which is the largest single source of reimbursement for home health care services? A. Medicaid B. Medicare C. Client's self-pay D. Private insurance

Which is the most important role of the nurse in using complementary and alternative therapies? A. Practicing guided imagery prior to surgery B. Educating the public about safety and effectiveness C. Providing nutrition supplements for weight gain D. Administering herbal supplements for anxiety

Which nursing student would most likely be held liable for negligence? A. A nursing student performs a dressing change using sterile technique and documents the presence of necrotic tissue in the wound. B. A nursing student administers medication to a resident while working as an unlicensed assistive personnel (UAP) at a local nursing home. C. A nursing student completes an incident report after administering a medication to a client who then experienced an adverse reaction to the medication. D. A nursing student reports that insulin was not administered to the client by the nurse on the previous shift.

Which refers to a person's ability to find and to receive care from a health care provider? A. Access to clinics B. Access to health care C. Access to nurses D. Access to doctors

Which statement best conveys the role of intuition in nurses' problem solving? A. In experienced nurses, intuition can be a valid replacement for scientific problem solving. B. Intuition can be a clinically useful adjunct to logical problem solving. C. Intuition is reliable when those nurses implementing it have a special "gift." D. Intuition is an unreliable mode of thinking that should be avoided.

Which statement most accurately reflects the intent of secondary care? A. Advanced practice nurses and specialist physicians treat rare and complex disease states. B. Specialists provide psychiatric care, same-day surgery, and general hospital care. C. Nurse midwives provide outpatient care. D. Primary care physicians and nurse practitioners care for clients with common health problems.

While assessing a client, the client tells the nurse that he is a follower of traditional Chinese medicine and the concept of qi. Based on the nurse's understanding of this concept, which treatment modality would the nurse expect the client to mention? A. Therapeutic Touch (TT) B. Physiotherapy C. Acupuncture D. Allopathy

Who provides care in the primary nursing model? A. Nursing students B. Registered nurses C. Masters' prepared nurses D. Nurse assistants

The risk for developing colorectal cancer during one's lifetime is 1 in 19. Nurses play an integral role in the promotion of colorectal cancer screening. What are risk factors for colorectal cancer? Select all that apply. A. a diet high in fruits, vegetables, and whole grains. B. a positive family history C. age 50 and older D. a history of inflammatory bowel disease

B, C, D

A nurse is reading a journal article about how health care delivery in the United States compares with that in other nations in the world. The article goes on to describe areas for which the United States ranks near the bottom in comparison with other nations. The nurse demonstrates understanding of this article by identifying which area as being deficient in the United States when compared with other nations? Select all that apply. A. Cancer B. Infant mortality C. Obesity D. Drug-related deaths E. Heart disease

B, C, D, E

The nurse is teaching a client about ways in which to reduce sodium in the diet. Which foods will the nurse recommend that the client avoid? Select all that apply. A. whole wheat pasta B.cured ham C. bacon D.whole milk E. egg yolks F. table salt

B, C, F

While managing the care of clients with tube feeding, the nurse visualizes aspirated contents, checking for color and consistency. Which statements should inform the nurse's interpretations? Select all that apply. A. A small amount of mucus may be seen immediately after NG insertion. B. Gastric fluid is green with particles, off-white, or brown if old blood is present. C. Respiratory or tracheobronchial fluid may be tinged with blood in an acutely ill client. D. A client's intestinal aspirate appears to be straw-colored E. Intestinal aspirate may be black if stained with bile. . F. Respiratory or tracheobronchial fluid is usually off-white to tan.

B, D, F

Which qualities are essential for a community-based nurse? Select all that apply. A. Ability to delegate client care tasks to unlicensed assistive personnel B. Effective communication skills C. Strong knowledge foundation D. Keen physical assessment skills E. Competence in assisting with minor surgical procedures

B,C,D

Which statements about the nursing process are accurate? Select all that apply. A. It is essential for identifying medical diagnoses. B. It is an orderly way of solving client problems. C. It is important for providing individualized care to each client. D. It helps to emphasize the client's active role in making decisions. E. It focuses on the care of adult clients.

B,C,D

During an annual physical examination the client reports feeling a lack of muscle energy when walking and doing simple chores around the house. When reviewing the client's diet, deficiencies in which vitamin would be associated with the symptoms reported? Select all that apply. A. Vitamin D B. Thiamine C. Folic acid D. Niacin E. Vitamin C

B,D

A nurse is preparing a presentation for a group of staff nurses about the rules affecting nursing practice and the parties involved. When describing the role of different sources for the rules, which issue would the nurse identify as being addressed specifically by state legislation? Select all that apply. A. Position statements related to medication administration B. Educational requirements of nurses C. Unprofessional conduct D. Clinical procedures E. Scope of practice

B,E

A 46-year-old obese client has been diagnosed with hypertension and type 2 diabetes. The client acknowledges the need to lose weight. The client recently visited a local fitness club, obtained a membership, and has signed up for their next water aerobics class. According to the Transtheoretical Model of Change, what stage of change is this client in related to her weight loss? A. Maintenance B. Contemplation C. Preparation D. Precontemplation

A client asks the nurse about the use of healing touch. Which statement regarding healing touch is accurate? A. Supplemental music is used during healing touch. B. Healing touch is too expensive for most clients. C. Healing touch does not use injections. D. Aromatherapy is used in healing touch.

A client has just had abdominal surgery, and the nurse is consulting with him about his diet now that he is allowed to eat. Which nutrient is most important for wound healing? A. vitamins B. carbohydrates C. protein D. fats

A client informs the nurse about leaving the health care facility because the client is not satisfied with the treatment. The nurse knows that the client's treatment is incomplete and further testing and evaluations are scheduled. Which action by the nurse would be most appropriate to prevent false imprisonment? A. Tell the client that the client will not be able to get access again. B. Call the health care provider to speed up the discharge process. C. Ask the client to sign a release without medical approval. D. Restrain the client to prevent from leaving.

A client is discussing vitamin and mineral intake with the nurse. Which client statement requires further nursing teaching? A. "My body does not make its own vitamins." B. "I drink orange juice fortified with added calcium." C. "My husband and I are ordering a product that has megadoses of vitamins." D. "Cooking can change the vitamin contents in foods."

A client is in a persistent vegetative state. The client has no immediate family and is a ward of the state. Under these circumstances, who will speak on this client's behalf? A. A best friend B. A church-appointed guardian C. A surrogate decision maker D. A significant other

A client is in the last stage of labor. During each contraction, she is focusing on her husband's voice and a picture brought from home. She is demonstrating which type of meditation? A. Expressive B. Reflective C. Concentrative D. Receptive

A client living alone has degenerative joint disease, hypertension, and neuropathy. It is difficult for the client to bathe, and the client's blood pressure is unstable. Which type of care would this client benefit from most? A. Respite care B. Acute care C. Home care D. Ambulatory care

A client suffers from chronic pain. The nurse suggests the client have monthly massages. This is an example of: A. adjuvant medicine. B. palliative medicine. C. alternative medicine. D. allopathic medicine.

A client uses meditation as part of treatment for a neuromuscular disease. How can the nurse best facilitate continuation of this treatment while the client is hospitalized? A. Raise the head of the client's bed up and provide pillows for support B. Check the meditation practitioner's credentials prior to treatment C. Provide a quiet uninterrupted period for meditation D. Monitor the client's vital signs during the meditation session

A client who has a bacterial infection develops an abscess that needs to be drained. What drainage system would most likely be used in this situation? A. Jackson-Pratt drain B. Hemovac drain C. Penrose drain D. Wound pouching

A client with end-stage renal disease decides against further treatment and requests a "Do Not Resuscitate" (DNR) order. The DNR status is part of the change-of-shift report. The client stops breathing and a nurse begins cardiopulmonary resuscitation. The family is upset and makes a complaint to the charge nurse. The charge nurse appropriately identifies that nurse has committed: A. assault. B. defamation. C. battery. D. fraud.

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

A clinic-based nurse in a sparsely populated remote area far from a regional hospital is working with other local health care team members on a plan to improve client health and outcomes. The team has decided that which health care delivery system would best meet the population's needs? A. A multi-specialty group practice D. A preferred provider organization (PPO) C. A health clinic run by an advanced practice registered nurse (APRN) D. A medical neighborhood

A home health care nurse is explaining to an emergency room nurse how nursing care in the home setting differs from that in the hospital setting. Which statement by the home health care nurse would be most appropriate? A. "Each team member works independently of other team members." B. "It requires that you have high-level critical care skills." C. "The client and family are in control of the setting, not the nurse." D. "You need a graduate degree to specialize in home health care."

A hospital has begun to expand home health services to its clients. Which reason is the most likely cause for the expansion of these services? A. The increase in the incidence and prevalence of infectious diseases B. The need for decreased financial expenditures C. The change to shorter hospital stays D. Changes to the structure of Medicare and Medicaid

A nurse from the ambulatory surgical center is preparing discharge instructions for a client who has had pelvic surgery. Which criterion would the client need to demonstrate to ensure that she is ready for discharge? A. eat without nausea B. verbalize absence of pain C. void normally D. exhibit no bleeding

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. Glascow scale

A nurse is attempting to calm an infant in the nursery. The nurse responds to the highest developed sense by: A. softly humming a song near the neonate. B. offering the neonate infant formula. C. swaddling the child and gently stroking its head. D. staring into the neonate's eyes and smiling.

A nurse is caring for a client who has a malabsorption disease. The nurse should understand that which structure in the gastrointestinal system absorbs the majority of digested food and minerals? A. Stomach B. Large intestine C. Small intestine D. Liver

A nurse is caring for a client with an ostomy pouch. When should the nurse ask the client to empty the pouch? A. when the client is about to take a bath B. when the client is ready to sleep C. when the pouch is one-third to one-half full D. when the pouch is completely filled

A nurse is caring for a client with pneumonia. Which task is most appropriate for the nurse to delegate to an experienced unlicensed assistive personnel (UAP)? A. Instructing the client about the need to alternate activity with rest B. Assessing for shortness of breath C. Obtaining vital signs every 4 hours D. Administering nebulizer treatments as needed

A nurse is caring for an older adult client in the home. The nurse concludes that the client needs an X-ray to determine whether the client has pneumonia and requires oxygen for shortness of breath. The nurse calls to inform the physician of the client's status and then makes arrangements to carry out the physician's orders. In this scenario, what role does the nurse play? A. Advanced practitioner B. Nurse practitioner C. Case manager D. Clinical nurse specialist

A nurse is checking a client's capillary blood glucose level. Which nursing action is most appropriate? A. Wipe the test site with an alcohol swab after testing. B. Cleanse the test strip with an alcohol swab prior to inserting it in the meter. C. Touch the test strip directly to a drop of blood. D. Have the client make a fist to encourage blood flow.

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? A. Clean the wound in a circular pattern, beginning on the perimeter of the wound. B. Once the wound is cleaned, gently dry the wound bed with an absorbent cloth. C. Clean the wound from the top to the bottom and from the center to outside. D. Use clean technique to clean the wound.

A nurse is completing a health history with a newly admitted client. During the interview, the client presents with an angry affect and states, "If my doctor did a good job, I would not be here right now!" What is the nurse's best response? A. Stand and say, "I can see this interview is making you uncomfortable, so we can continue later." B. Nod and say, "I agree. If I were you, I would get a new doctor." C. Be silent and allow the client to continue speaking when ready. D. Smile and say, "Don't worry, I am sure the physician is doing a good job."

A nurse is documenting assessment data for a new client. What is the best source of assessment information for the nurse? A. Physician B. Nursing plan of care C. Client D. Family and friends

A nurse is monitoring a client post cardiac surgery. What action would help to prevent cardiovascular complications for this client? A. Keep the client from ambulating until the day after surgery. B. Keep the client cool and uncovered to prevent elevated temperature. C. Implement leg exercises and turn the client in bed every 2 hours. D. Position the client in bed with pillows placed under his knees to hasten venous return.

A nurse is preparing to enter a client's room to perform wound care. The shift report revealed that this client has a tunneling wound in the sacral area that cannot be staged. The wound was also documented as having a foul odor. The nurse is nervous because the nurse has not performed wound care on a complex wound in the past. Using effective intrapersonal communication, this nurse should: A. inform the client that several nurses will be needed to care for this wound. B. ask the charge nurse to change the assignment. C. tell oneself to "remain calm" and remember that the nurse was trained to perform this skill. D. tell the unlicensed assistive personnel (UAP) to gather supplies and to prepare to cleanse and dress the wound.

A nurse is providing supportive care to a client diagnosed with a terminal illness who is not expected to live past the next 3 months or so. The nurse is likely working in which setting? A. Parish nursing B. Palliative care C. Hospice care D. Respite care

A nurse is teaching a client experiencing stress about how relaxation helps to reduce the effects of stress on the body. Which underlying concept would the nurse integrate into the explanation about how relaxation works? A. Slows circulation throughout the body B. Increases the body's natural immunity C. Helps to increase the effects of parasympathetic nervous system on the mind and body D. Activates natural pleasure centers

A nurse manager informs the staff members during a meeting that unlicensed assistive personnel will no longer be allowed to check clients' blood glucose levels. The nurse manager informs the group that this is a new policy on the unit and that discussions will not change the enforcement of this policy. What type of leadership style is the nurse manager demonstrating? A. Transformational B. Laissez-faire C. Autocratic D. Democratic

A nurse manager reviews an employee's contribution to the nursing division annually. This process is: A. interpreting quality indicators. B. employee's job satisfaction survey. C. performance appraisal. D. reward and development survey.

A nurse teaches deep breathing exercises to a preoperative client. Which action should the nurse perform? A. Assist or place the client in a supine position for the exercises. B. Instruct the client to place the palms of both hands along the upper posterior rib cage. C. Instruct the client to exhale gently and completely before inhaling. D. Instruct the client to breathe in through the nose as deeply as possible and hold the breath for 10 seconds.

A nursing student is teaching healthy nutrition to a client who is vegetarian. Which statement by the nursing student requires the nursing instructor to intervene? A. "Vegans consume plants sources for protein. " B. "Vegetarians have a lower incidence of colorectal cancer than people who eat high fat diets." C. "Obesity is closely linked with vegetarianism." D. "Protein complementation is important so that you get the right amount and proportion of amino acids needed."

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client? A. Evisceration of the viscera B. Infection of the wound C. Dehiscence of the wound D. Herniation of the wound

A successful discharge includes effective planning. Identifying and meeting client needs beyond the acute care facility reduce readmissions. Which nursing role is of great importance to this success? A. Clinician B. Caregiver C. Coordinator D. Nurse practitioner

Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which is not one of these factors? A. The heart must be able to pump adequately. B. The volume of circulating blood must be sufficient. C. Local capillary pressure must be lower than external pressure. D. Arteries and veins must be patent and functioning well.

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. Visible waves of abdominal peristalsis B. Increased anal area pigmentation C. Hyperactive bowel sounds D. Dry, hard stool

An 82-year-old client is being discharged from the hospital following a bowel resection. The client lives alone and the client's family is out of town. Which factor will have the greatest effect on the client's home care management? A. Psychosocial needs B. Medication management C. Support system D. Transportation

An older adult client informs the nurse that foods don't taste or smell the same and eating is a chore. What suggestion can the nurse provide to the client to address this age-related change? A. Try eating foods with the same textures and aromas. B. Try eating 2 to 3 foods at a time. C. Try eating foods that are attractive and at the proper temperature. D. Use spicy condiments to add flavor.

An older adult woman who is incontinent of stool following a cerebrovascular accident will have which nursing diagnosis? A. Constipation related to physiologic condition involving the deficit in neurologic innervation, as evidenced by fecal incontinence B. Diarrhea related to tube feedings, as evidenced by hyperactive bowel sounds and urgency C. Bowel Incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate D. Fecal Retention related to loss of sphincter control, and diminished spinal cord innervation related to hemiparesis

During a client interview, the client tells the nurse about using ginkgo biloba to improve memory. When reviewing the client's medication history, which medication if used by the client would be a cause for concern? A. Azithromycin B. Acetaminophen C. Warfarin D. Guaifenesin

During a home care visit to a home-bound older client, the client's spouse, who is the caregiver, verbalizes anger, fatigue, and sleeplessness. Which recommendations by the nurse would be most effective in relieving caregiver role strain? A. Voluntary services B. Palliative care C. Respite care D. Hospice care

During the initial visit to a client's home, the nurse should provide the client and family with what information? A. Information on other clients in the area with similar health care needs B. Dates and times of all future home care visits C. Available community resources to meet their needs D. The nurse's phone number and home address

In the 1980s, the nursing care delivery model shifted from a team nursing model to a: A. managed care model. B. modular care model. C. primary nursing model. D. clinical specialist model.

LOOK OVER THIS AGAIN The nurse should consider which client aspect as nonverbal communication? A. The client's values and beliefs B. The client's religious practices C. The client's tone of voice D. The client's accent

Professional regulations and laws that govern nursing practice are in place for which reason? A. To ensure that enough new nurses are always available B. To ensure that practicing nurses are of good moral standing C. To protect the safety of the public D. To limit the number of nurses in practice

The Nursing Agenda for Health Care Reform (American Nurses Association [ANA]) identifies the recipients of health care. This reform's main focus is on: A. accurate assessment in the acute health care setting. B. better connectivity through the use of technology. C. health promotion. D. high-quality disease management.

The client is talking to the nurse about recent health problems of immediate family members and the strain the client has been under trying to care for them. The client begins to cry. What response by the nurse demonstrates the most empathy? A. "It's okay to cry. Sometimes that helps us to feel better." B. "It is difficult when family members are ill. It helps if you take some time for yourself." C. "Just take your time. I am listening." D. "I know how you feel. I was the primary caregiver for my father when he was dying."

The client recently immigrated from Mumbai, India. The client was just admitted to the nurse's unit postoperatively following gallstone removal. The client does not speak the dominant language. When using the hospital's interpretive services, which is most important? A. Have the interpreter write out all of the information listed in the unit brochure. B. Give all of the discharge instructions at once. C. Speak directly to the client. D. Ensure that family members are present.

The client reports to the clinic as ordered by the primary care provider for counseling on weight loss to improve overall health. The client received printed information in the mail to review before the session, and reports having read through it before the appointment. Which client statement alerts the nurse to a need for clarification and further education? A. "I can lower my blood pressure by losing weight." B. "Osteoarthritis in my knees may be because of my weight." C. "I will be doing well if I lose between 5 and 10 lb (2.3 and 4.5 kg) per week." D. "I can monitor my caloric intake by measuring portions."

The implementation of diagnosis-related groups (DRGs) by Medicare in 1983 affected hospitals in which way? A. Part A of Medicare is voluntary and is paid for by a monthly premium. B. Benefits and reimbursement cannot be changed annually. C. Medicare pays only the amount of money preassigned to a treatment for a diagnosis. D. Part B of Medicare covers most inpatient and outpatient costs.

The new nurse is having difficulty managing the time required to care for a group of complex clients and is several hours behind in completing nursing interventions. Which intervention should the nurse complete first? A. Perform a dressing change to an abdominal abscess that is three hours behind schedule. B. Complete a medication reconciliation form on a client who has recently been admitted to the hospital. C. Administer a dose of digoxin that is two hours behind schedule. D. Obtain discharge orders for a client who is ready to be transferred to a long-term nursing facility.

The nurse has recently been promoted to nurse manager on an oncology unit and has decided to be the sole decision maker regarding issues that concern the unit. Which type of leadership style is the nurse embodying? A. Democratic B. Quantum C. Autocratic D. Laissez-faire

The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly? A. The nurse uses a safety pin to attach the pad to the bedding. B. The nurse places the heating pad under the client's neck. C. The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly. D. The nurse covers the heating pad with a heavy blanket.

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture? A. Cleanse the wound after obtaining the wound culture. B. Utilize the culture swab to obtain cultures from multiple sites. C. Keep the swab and the inside of the culture tube sterile. D. Stroke the culture swab on surrounding skin first.

The nurse is caring for a client who presents with polydipsia, polyphagia, and polyuria. The client's laboratory test results reveal an increased HgbA1C level, which could indicate increased blood glucose levels. What is the next step for the nurse to take based on the nursing process? A. Identify outcomes for the client with the client's input. B. Administer a prescribed medication to decrease the client's blood glucose level. C. Analyze the data and create an individualized nursing diagnosis. D. Follow up with the client later to determine whether the client's laboratory test results improve.

The nurse is caring for four clients. The nurse recognizes that which client's lifestyle choice contributes most highly to risk for development of cardiometabolic syndrome? A. 33-year old who consumes a strict vegan diet B. 19-year old who runs a mile every other day C. 28-year old who eats fast food daily D. 41-year old who has a family history of cancer

The nurse is met in the staff lounge by the nurse who has been caring for the client team on this shift. The off-going nurse says, "Sorry, but I have to get out of here." The nurse then gives a quick overview of each client on the team and says, "All the rest is in the chart if you need anything." Which essential part of the handoff is missing? A. The oncoming nurse's chance to check intravenous (IV) sites and fluids B. The chance for the oncoming nurse to assess the clients C. The opportunity for the oncoming nurse to ask questions D. The oncoming nurse's opportunity to meet new clients

The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the best action by the nurse at this time? A. Gently rub and massage the area to warm it up. B. Document the findings in the client's medical record. C. Discontinue the therapy and assess the client. D. Notify the health care provider of the findings

The nurse is providing care to a client who had orthopedic surgery. The nurse has medicated the client for pain. However, the client reports that the pain is unrelieved. The nurse takes no further action regarding assessment and intervention for the client's pain. The nurse does not notify the surgeon regarding the client's pain. The nurse's failure to take further action represents which element of liability in this case? A. Duty B. Damages C. Breach of duty D. Causation

The nurse is providing care to several clients on a medical-surgical unit. For which client's plan of care should the nurse include information regarding extended care? A. A client who developed sepsis after a ruptured polyp B. A middle-aged client who had a knee replacement C. An older adult client who fell at home and required a hip replacement D. A client who had a cholecystectomy

The nurse is providing health teaching for four clients. Which client should consider a colonoscopy screening? A. 67-year-old client with constipation B. 33-year-old client who reports painful elimination C. 50-year-old client with a family history of polyps D. 42-year-old client with diarrhea twice weekly

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. "The bulb-like system will stay in place permanently after your mastectomy." B. "You will receive medication through this device." C. "It provides a way to remove drainage and blood from the surgical wound." D. "This drain minimizes the chance for bacteria to enter the surgical site."

The nurse manager calls a staff into a unit meeting to discuss patient satisfaction. During the meeting, several staff members assume control. The nurse manager does not intervene to regain control of the group. Which type of leadership style is the nurse embodying? A. Autocratic B. Democratic C. Laissez-faire D. Quantum

The nurse recognizes that a new mother is having difficulty breastfeeding. The nurse demonstraties various positions in which to hold the baby while feeding. The nurse also educates the mother on ways to ensure proper latching. The new mother attempts to breastfeed the baby again using the new techniques and is successful. Which statement in this scenario illustrates Lewin's stage of refreezing? A. The nurse recognizes that a new mother is having difficulty breastfeeding. B. The nurse also educates the mother on ways to ensure proper latching. C. The new mother attempts to breastfeed the baby again using the new techniques and is successful. D. The nurse demonstrates various positions in which to hold the baby while feeding.

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

The student nurse is administering a large-volume enema to a client. The client reports abdominal cramping. What should the student nurse do first? A. Increase the flow of the enema for approximately 30 seconds then decrease it to the prior flow rate. B. Increase the flow of the enema until all of the solution has been administered. C. Stop the administration of the enema momentarily. D. Stop the administration of the enema and notify the physician.

Two staff nurses on a unit disagree with one another over certain key aspects of providing client care. The nurse manager of the unit arranges a meeting with the charge nurse and the two staff nurses at a mutually agreed-upon time to discuss this situation. This activity is most accurately described as what? A. Delegation B. Problem solving C. Conflict resolution D. Client protection

When a nurse is planning for learning, who must decide who should be included in the learning sessions? A. The client and the client's family B. The doctor and nurse C. The nurse and the client D. The health care team

When performing a dressing change, the home care nurse notes that the base of the client's leg wound is red and bleeds easily. What is the appropriate action by the nurse? A. Notify the physician. B. Send the client to the emergency room. C. Document the findings. D. Consult a wound care nurse.

Which action exemplifies the purpose of evaluation in the nursing process? A. Develop an individualized plan of client care. B. Determine the client's health status, self-care ability, and need for nursing. C. Decide whether to continue, modify, or terminate client care. D. Develop a prioritized list of nursing diagnoses.

Which activity by the nurse exhibits the role of family educator? A. Obtaining a sputum specimen for laboratory testing. B. Arranging for a swallowing evaluation by the speech pathologist. C. Demonstrating how to suction the oropharynx. D. Supporting the client's wish to die at home.

Which client is most likely to require interventions in order to maintain regular bowel patterns? A. a woman 59 years of age who has recently begun hormone replacement therapy B. a client with hypertension who takes a diuretic and adrenergic blocker each morning C. a client whose neuropathic pain requires multiple doses of opioids each day D. a client who has a history of atrial fibrillation requiring daily anticoagulants

Which documentation example best reflects the complexity of client teaching by the nurse? A. "Client return demonstrated how to use glucometer." B. "Told client to take antibiotic as ordered." C. "Client and spouse taught how to use phone app to count carbohydrates; client return demonstrated carb counting for a hypothetical meal." D. "Taught client about peak flows; client verbalized understanding."

Which government policy addresses penalizing hospitals for readmissions of clients with certain diagnoses within 30 days after discharge? A .Americans with Disabilities Act B. National Commission for Minorities C. Affordable Care Act D. American Nurses Association Bylaws

Which is a skill appropriate to use in therapeutic communication? A. Use cliches to enhance a client's understanding of information. B. Avoid the use of periods of silence. C. Control the tone of the voice to avoid hidden messages. D. Be precise and inflexible regarding the intent of the conversation.

Which is the acute care setting for people who are too ill to care for themselves at home, are severely injured, or require surgery? A. Primary care centers B. Day care centers C. Hospitals D. Ambulatory care centers

Which is the best example of person-centered care provided by a registered nurse? A. Insertion of a nasogastric tube for gastric decompression B. Development of a plan of care for a new admission C. Reassuring a client who is anxious about a procedure D. Administration of pain medication every 4 hours to a client who is postoperative

Which measure would the nurse implement for prevention of deep vein thrombosis (DVT) in a postoperative client? A. Educate the client about the use of an incentive spirometer. B. Encourage the client to elevate the head of the bed. C. Place graduated compression stockings on the client. D. Elevate bilateral legs when the client is lying in bed.

Which member of the health care team is most often responsible for providing the order that will begin a client's course of home health care? A. The hospital discharge planner B. The registered nurse C. The physician D. The case manager

Which nursing action will best promote pain management for a client in the postoperative phase? A. Providing food and medication B. Dimming the lights C. Performing relaxation techniques D. Breathing into a paper bag

Which nursing model results in the greatest continuity of care? A. Team nursing B. Modular nursing C. Primary nursing D. Total client care

Which role is the home health nurse exhibiting when demonstrating how to suction the oropharynx of the client? A. Caregiver B. Care coordinator C. Educator D. Advocate

Which statement describes the person who is likely the most motivated to learn? A. A 52-year-old male who has been hired to drive the client home from the clinic B. A 29-year-old male whose significant other is insisting on the client receiving the education C. A 70-year-old female who is the client's spouse and is learning the care so the client can come home D. A 25-year-old female who just completed a course of physical therapy

Which statement is true of the nursing process? A. It is more appropriate in medical surgical settings than community health care. B. It is a valid alternative to using intuition to respond to nursing situations. C. Scientific problem solving can occur within the nursing process. D. Trial-and-error problem solving is incongruent with the nursing process.

Which statement is true when comparing home care with acute care? A. The nurse and the client work independently of each other. B. The client directs the education of all caregivers. C. The nurse is the guest in the client's home. D. The nurse directs all aspects of the home.

Which statement, if made by an adolescent preparing for abdominal surgery, would indicate to the nurse that the client requires additional instruction? A. "I might be sick to my stomach and throw up after surgery." B. "When I can eat again, the best meal would be steak and orange juice." C. "I can have a hamburger and French fries as soon as I wake up." D. "The better I eat before surgery, the more likely I will heal."

Which task may be safely delegated to unlicensed assistive personnel (UAP)? A. Inserting a nasogastric (NG) tube into a client with persistent nausea B. Administering tube feeding to a client who has had a stroke C.Feeding a client who is at risk for aspiration D. Removing a client's NG tube after surgery

Which type of home healthcare agency is a local health department? A. Institution-based agency B. Private, proprietary agency C. Official or public agency D. Private not-for-profit agency

The nurse has entered the room of a newly admitted client who immediately reports feeling short of breath. After identifying this as the client's problem, the nurse uses the process of scientific problem solving. Place the steps in the order the nurse would follow. A. Make a plan for action. B. Evaluate. C. Collect assessment data. D. Perform hypothesis testing. E. Formulate a hypothesis

C E A E D

A client admitted to the hospital is diagnosed with cancer. The client is assigned a nurse who will be the central point of contact for all of the client's care. Which role is the nurse filling? A. Client navigator B. Care coordinator C. Case manager D. Nurse navigator

A client being discharged from the hospital asks the nurse, "When I go visit my family out of state, should I take my living will with me, or do I need a new one for that state?" Which is the most appropriate response by the nurse? A. "As long as your family knows your medical wishes, you will not need it." B. "We have it on file here, so any hospital can call and get a copy." C. "A living will can only be used in the state in which it was created." D. "Take it with you. It is recognized universally in the United States."

A client comes into the clinic stating he has been experiencing insomnia for a couple of weeks. After a thorough exam revealed no physiological cause for the symptom, the nurse practitioner suggested the use of aromatherapy. Which of the following might the nurse suggest for its use in helping insomnia? A. Ginger B. Peppermint C. Almond D. Chamomile

A client has a nursing diagnosis of Imbalanced Nutrition, Less Than Body Requirements. The client's expected outcome is: A. to eat dessert after every meal. B. to maintain a clear liquid diet. C. to gain 5 lb (2.25 kg) in 1 day. D. to consume 80% of diet tray for each meal.

A client has a prescription for amoxicillin 500 mg P.O. every 8 hours. The nurse administers the medication via the intravenous route. Based on the nurse's action, the client develops complications and has an increased length of stay. The client files a lawsuit against the facility and the nurse. Which legal action has the nurse's attorney identified that meets the criteria for the client's lawsuit? A. Battery B. Assault C. Negligence D. Malpractice

A client has arrived to the postanesthesia care unit (PACU) and is drowsy with a respiratory rate of 12 breaths per minute. What would be an accurate interpretation by the nurse? A. The client needs to have the neurologic status fully evaluated. B. The procedural physician should be notified immediately of client findings. C. The client should be returned to the operating room for further evaluation. D. This is an expected finding in the immediate postoperative period.

A client informs the nurse that they have been following a strict low-calorie diet and skipping meals to lose weight faster. The client reports feeling upset about not losing any weight and wants to know what to do. What is the best response by the nurse? A. "Are you sure you are cutting back as much as you say you are? You should be losing weight." B. "If you keep cutting out a lot of calories, you will lose weight." C. "Losing weight is hard and sometimes no matter what you do, it doesn't work." D. "The body will go into starvation mode by slowing metabolic rate and it will be hard to lose weight."

A client is scheduled for hip replacement surgery this morning but admits to the nurse that he had a small piece of toast and some water after waking up. What is the nurse's most appropriate response? A. Explain the rationale for preoperative fasting to the client. B. Assess the client's abdomen by inspection and auscultation. C. Ask the client if he did not understand the preoperative instructions. D. Inform the anesthesiologist or surgeon of this fact.

A client is scheduled for thoracentesis. The nurse assesses that the client appears anxious about the procedure and needs honest support and reassurance. What is the most appropriate response by the nurse to this client? A. "I will be by your side throughout the procedure; the procedure will be painless if you don't move." B. "The procedure may take only 2 minutes, so you might get through it by mentally counting up to 120." C. "You may feel very uncomfortable when the needle goes in, but you should breathe rhythmically." D. "The needle causes discomfort or pain when it goes in, but I will be by your side throughout and will help you hold your position."

A client's hand was severely wounded upon coming in contact with a running lawn mower blade. The nurse notes that large amounts of flesh are missing and the bones of two fingers are visible. How will the nurse document this assessment finding? A. puncture B. laceration C. contusion D. avulsion

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

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

A home care nurse delivers care that incorporates a philosophy that focuses on connections and interactions between parts of the whole. Which term best describes this philosophy? A. Complementary therapy B. Integrative care C. Homeopathy D. Holism

A home health nurse is scheduled to make a visit to a client who was discharged from the hospital yesterday following an appendectomy. The nurse understands that the scope of practice for a home health nurse allows the nurse to perform which psychomotor tasks? A. Assessment, wound care, teaching, and prescribing pain medications B. Teaching, dietary instruction, and monitoring for infection only C. Assessment, reporting back to the agency and physician, and prescribing antibiotics D. Wound care, medication administration, teaching, and ensuring a reasonably safe environment

A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed, the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do? A. Administer an additional liter of intravenous fluids. B. Check the client's skin turgor. C. Formulate a plan of care based on risk for dehydration. D. Determine whether the prescribed treatment was effective.

A nurse and the facility have been named as defendants in a malpractice lawsuit. In addition to the nurse's attorney, whom else would be appropriate for the nurse to talk with about the case? A. The plaintiff's lawyer B. A colleague C. The local press D. The agency's risk manager

A nurse can best help a client who is undergoing chemotherapy and using guided imagery with this by doing which of the following? A. Explaining to the client that it is not a good idea to record their own imagery tape. B. Helping the client learn about the different poses that can be performed. C. Promoting the client's use of imagery only after a stressful event occurs. D. Assisting the client to find an appropriate imagery tape to use.

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

A nurse has been caring for a client who had a myocardial infarction 2 days ago. During the morning assessment, the nurse asks the client how the client feels. Which scenario warrants further investigation? A. The client is sitting in a chair and states, "I feel a lot better than I did yesterday. B. The client looks at the nurse and states, "I am still not feeling my best." C. The client smiles at the nurse and states, "I cannot wait to go home." D. The client stares at the floor and states, "I feel fine."

A nurse has developed a plan of care for an adult client. What nursing function is important when using nursing diagnoses to guide the care of this client? A. Add a new nursing diagnosis in the nurse's own words to individualize the plan of care. B. Do not allow the client to review the client's own nursing diagnoses. C. Keep resolved nursing diagnoses as part of the plan of care in case the related problems return. D. Prioritize the nursing diagnoses.

A nurse in a clinic is caring for a female client who is of childbearing age. Which vitamins or minerals should the nurse recommend to prevent neural tube defects during pregnancy? A. Vitamin E B. Ascorbic acid C. Vitamin D D. Folic acid

A nurse is assessing the stoma of a client with an ostomy. Which intervention should the nurse perform when providing peristomal care to the client to preserve skin integrity? A. Avoid using commercial skin preparations. B. Clean it with a dry, cotton bandage. C. Avoid applying a barrier substance. D. Wash it with a mild cleanser and water.

A nurse is assessing vital signs on a pregnant client during a routine prenatal visit. The client states, "I know labor will be so painful, it sounds awful. I am sure I will not be able to stand the pain; I really dread going into labor." What is the best response from the nurse? A. "I would recommend keeping a positive attitude." B. "Don't worry about labor, I have been through it and it is not so bad." C. "There are many good medications to decrease the pain; it will not be so bad." D. "You're worried about how you will tolerate the pain associated with labor."

A nurse is caring for a client who has undergone coronary angioplasty. The cardiac monitor is showing abnormal electrocardiogram waves, indicating atrial fibrillation. The nurse does not recognize the importance of the sign; as a result, the client's condition deteriorates and the client has to be taken up for an emergency procedure. Which describes the nurse's legal liability? A. Felony B. Slander C. Defamation D. Tort

A nurse is caring for a client with a gastrostomy tube in place. Which is an accurate guideline for care of the insertion site? A. If the gastrostomy tube is new, dip a cotton-tipped applicator into hydrogen peroxide and apply pressure to clean the site. B. Adjust or lift the external disk for the first few days after placement to keep crusts from forming. C. If the gastrostomy tube is new and has crusts or drainage, do not disturb the site by cleaning it. D. If the gastric tube insertion site has healed and the sutures are removed, use soap and water to clean the site.

A nurse is caring for a hospitalized client who states: "I feel so sick all the time; my aura must be disturbed by all of these bad force fields." What is an appropriate NANDA-I diagnosis for this client? A. Hopelessness B. Impaired coping C. Social isolation D. Disturbed energy field

A nurse is completing a health history on a client who has a hearing impairment. Which action should the nurse take first to enhance communication? A. Use facial and hand gestures B. Contact a person skilled in sign language C. Provide paper and pencil for written communication D. Assess how the client would like to communicate

A nurse is discussing the benefits of smoking cessation with a client. The nurse informs the client that smoking cessation will reduce the client's risk for cancer, improve respiratory status, and enhance the quality of life. The nurse also shares a personal story of smoking cessation, provides information on other individuals who have successfully quit, and encourages the client to attend a support group for smoking cessation. The client discusses feelings on smoking cessation and verbalizes a desire to quit smoking. What type of counseling did the nurse provide to this client? A. Long-term B. Developmental C. Situational D. Motivational

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

A nurse is learning about religious dietary restrictions at a nursing conference. Which religious meal selection should the nurse understand is appropriate? A. Orthodox Jews: Grilled pork chop B. Mormons: Toast with coffee C. Orthodox Jews: Grilled shrimp D. Hindus: Vegetable plate

A nurse is reading a journal article about providing individualized care. Which aspect would the nurse most likely read about as the almost universally accepted method for providing nursing care? A. Experience B. Reflection C. Clinical reasoning D. Nursing process

A nurse is teaching a student nurse how to manage unexpected events during the removal of a nasogastric tube. Which action should the nurse recommend? A. Replace the NG tube if the client experiences nausea within 6 hours of removal. B. If epistaxis occurs with removal of the NG tube, ensure that the client is in a supine position with an ice pack applied. C. If the client experiences pain during removal, apply petroleum jelly to the skin near the exit site. D. If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider.

A nurse is working with a 46-year-old woman who is working to lose weight. Based on recommendations from the USDA regarding diet modification, which is not appropriate advice for this client? A. Make fruits and vegetables at least half of total food intake. B. Drink nonfat or 1% milk. C. Eat a variety of enjoyable foods, but less quantity. D. Drink juice for majority of fluid intake.

A nurse is writing learner objectives for a client who was recently diagnosed with type 2 diabetes. Which statement best describes the proper method for writing objectives? A. The nurse plans learner objectives with another nurse before obtaining input from the client and family. B. The nurse writes one or two broad objectives rather than several specific objectives. C. The nurse writes general statements for learner objectives that could be accomplished in any amount of time. D. The nurse writes one long-term objective for each diagnosis, followed by several specific objectives.

A nurse prepares to insert a nasointestinal tube to provide nutrition to a client. Which guideline is recommended for this procedure? A. Add 16 to 18 in to the measurement obtained to ensure the tube comes to rest at the desired point. B. Administer an oral analgesia 30 to 45 minutes before attempting insertion. C. Position the bed flat and assist the client onto his or her left side. D. Begin by measuring from the tip of the client's nose to the earlobe to the xiphoid process.

A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action? A. Do not attempt to remove the sutures because the wound needs more time to heal. B. Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. C. Carefully pick the crusts off the sutures with the forceps before removing them. D. Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures.

A nurse who "unblocks" and "clears" congested areas of energy in a client's body to promote comfort is applying the phenomenon known as: A. "Unruffling" touch B. Tactile manipulation C. Interpersonal touch D. Therapeutic Touch (TT)

A nurse working for a home health agency is scheduled to evaluate a client with worsening heart failure to determine whether the client is a candidate for the new "Hospital at Home" program. Which statement accurately reflects an outcome for this program? A. Disease-specific quality standards have been found to be slightly worse than when clients are treated in the hospital. B. Clients in the acute care setting require fewer chemical and physical restraints. C. Clients and their family members have been found to be happier with stays in the hospital in which they have 24/7 access to the healthcare team. D. Clients in the "Hospital at Home" program have been found to require shorter lengths of stay than when admitted to the acute care setting.

A parent brings a 2-year-old child in to the clinic for a wellness check-up and informs the nurse that toilet training is not going well. The parent states,"I thought it would be easy to toilet train for bowel movements, but my child is still having accidents." What is the best response by the nurse? A. "There is nothing to worry about. Just keep the child in diapers until they stop having accidents." B. "There may be something wrong since your child should be toilet trained by 2 years-old." C. "You are putting too much pressure on yourself and your child to toilet train." D. "Children vary in their readiness but daytime bowel control may be attained at 30 months."

A parish nurse is preparing to provide a health promotion class to a group of adults in the parish. In preparing to meet the learning needs of this group, the nurse recognizes which as a characteristic of an adult learner? A. Previous experiences have little impact on learning. B. The material presented should focus on future application. C. Peer group acceptance is a critical issue for this age group. D. Their readiness to learn is often related to a developmental task or social role.

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child? A. In children younger than 2 years, the skin is thicker and stronger than in adults. B. A child's skin becomes less resistant to injury and infection as the child grows. C. An individual's skin changes little over the life span. D. An infant's skin and mucous membranes are easily injured and at risk for infection.

A pediatric nurse provides education to numerous clients. Which group of children benefits most from being involved in the teaching-learning process? A. Infants B. Preschoolers C. Toddlers D. School-age children

A postoperative client states "I don't understand why you are checking my skin on my back. My surgery was on my stomach." What is the nurse's best response? A. "The covers underneath you need to be straightened out. They look messy." B. "We wanted to be sure we didn't leave any sponges or syringes underneath you." C. "We needed to be sure you didn't have any skin breakdown before surgery." D. "The operating table is a firm surface; we need to be sure your skin looks okay."

A student nurse is assisting an older adult client to ambulate following hip replacement surgery when the client falls and reinjures the hip. Who is potentially responsible for the injury to this client? A. The hospital B. The student nurse C. The nurse instructor D. The student nurse, the nurse instructor, and the hospital

A unit-based infection control task force was developed in an attempt to reduce catheter-acquired infections. The group consists of 10 team members. During the past three meetings, one person dominated the meeting and did not allow other members ample time to speak. The best way to address the team dysfunction is to: A. pick a team leader who is not the dominant member. B. have group members issue a written warning to the dominant member. C. plan a meeting where the dominant person cannot attend. D. have group members confront the dominant member to promote the needed team work.

An HIV-positive client discovers that the client's name is published in a research report on HIV care prepared by the client's nurse. The client is hurt and files a lawsuit against the nurse. Which offense has the nurse committed? A. Negligence of duty B. Unintentional tort C. Defamation of character D. Invasion of privacy

An RN enters a client's room and observes the unlicensed assistive personnel (UAP) forcefully pushing a client down on the bed. The client starts crying and informs the UAP of the need to go to the bathroom. What action is the RN witnessing that should be immediately reported to the supervisor? A. Assault B. Fraud C. Defamation of character D. Battery

An elder adult client underwent a hip replacement and now states to the nurse, "My parents are coming to visit me today. I need to mow the lawn and run errands." The client is trying to get out of the bed. What does the nurse identify is occurring with this client? A. Narcotic overuse B. Boredom C. Dementia D. Delirium

An evening shift nurse is caring for a client scheduled for a colon resection in the morning. The client tells the nurse that the client is afraid of waking up during surgery. The best response by the nurse is to: A. ask the surgeon to come to the bedside to reassure the client. B. state "everyone is afraid of that." C. look directly at the client and state, "You are afraid of waking up during surgery." D. ask why the client thinks the client will wake up during surgery.

At the last hospital unit meeting, the policy for the insertion of Foley catheters was revised based on current evidence. The new nurse on the unit just learned "the old way" and is frustrated to now have to learn a new methodology. Several other nurses comment that the change is "all about money." The charge nurse must educate the staff about the importance of this new policy. Which explanation by the charge nurse is most appropriate? A. "Because our clients are considered consumers of care, they often understand the need to use specific methods based on research, and they want the best care for the lowest cost." B. "Cost is not a driver in quality health care delivery." C."Using evidence-based practice is the trend in providing quality care and may expose the client to better care implementation. None of our care methods are associated with cost." D. "Incorporating evidenced-based practice into our care routines links our interventions to valued outcomes, thereby increasing quality care. When we provide quality care, we can decrease cost."

Before starting the education process, the nurse should determine the preferred learning style, age and developmental level, capacity to learn, motivation level, readiness to learn, and learning needs of the client. How does this help the nurse in the client's health education? A. By reducing chances of any miscommunication B. By fulfilling the client's requirements C. By assisting the client's learning D. By implementing effective teaching

During an admission intake assessment, a nurse uses open-ended questions to gather information. An example of an open-ended question is: A. "Are you allergic to any medications?" B. "Can you tell me the medications you take on a daily basis?" C. "Do you have an advanced directive or a living will?" D. "Why did your physician send you here to be admitted?"

Each of the following facilitates a therapeutic nurse-client relationship except: A. reflection. B. active listening. C. rephrasing. D. closed-ended questions.

Each of the following facilitates a therapeutic nurse-client relationship except: A. reflection. B. rephrasing. C. active listening. D. closed-ended questions.

For which client would digital removal of stool be contraindicated? A. a client with a urinary tract infection B. a diabetic client with renal complications C. an older adult client who is incontinent of stool D. a client recovering from prostate surgery

Massage therapy is being used on clients during chemotherapy treatments. How does massage therapy help these patients? A. It uses slow, gentle physical movements to cleanse the body. B. It physically moves joints into proper alignment to relieve stress. C. It uses pressure to balance and increase flow of energy. D. It relaxes muscles to increase circulation and release tension.

Nurses use social media to share ideas, develop professional connections, access educational offerings and forums, receive support, and investigate evidence-based practices. Which is an example of the proper use of social media by a nurse? A. A nurse posts pictures of a client who accomplished a goal of losing 100 lb and later deletes the photo. B. A nurse describes a client on Twitter by giving the room number rather than the name of the client. C. A nurse describes a client on Twitter by giving the client's diagnosis rather than the client's name. D. A nurse uses a disclaimer to verify that any views the nurse expresses on Facebook are the nurse's alone and not the employer's.

One of the fastest growing venues of practice for the nurse is home health care. What is the basis for the growth in this health care setting? A. The chronic nursing shortage B. The preference of nurses to work during the day instead of evening or night shifts C. The focus on treatment of disease D. The discharge home of clients who are more critically ill

One significant change in the health care delivery system in recent years is earlier hospital discharges. What is one result of earlier hospital discharges? A. Clients are in the hospital for a longer period of time. B. Clients are locked into prenegotiated payment rates that have remained unchanged. C. Client use of ambulatory care has decreased. D. Clients with high home care needs are being discharged into the community.

Prior to the discharge of a client who is recovering from a stroke from an acute care facility, the nursing case manager has the nursing staff, client, client's family, physical therapist, and home health nurse meet. The most likely purpose of this meeting is to: A. evaluate the effectiveness of the hospitalization. B. provide client education. C. determine hospital-based services needed by the client. D. prepare the client for home care.

Public health nursing is the branch of nursing that: A. assesses individuals for community care. B. provides primary care to individuals. C. administers care for a defined geographic community. D. provides health care for the community.

The case manager works in a facility that supports a participative leadership style. Which action should the nurse recognize as an example of democratic leadership style? A. The nurse implementing the physician's written orders for client care B. The dietitian completing a nutritional assessment for a registered nurse (RN) C. The unlicensed assistive personnel (UAP) taking vital signs for several nurses D. The interdisciplinary health care team collectively developing plans of care for clients

The growth in home health care is largely attributed to which factor? A. Nurses' desire to work in the community B. The nursing shortage in hospitals C. The inability of hospitals to care for an increasing number of clients D. Early discharge of clients from the hospital setting

The nurse has observed that a client's food intake has diminished in recent days. What intervention should the nurse perform in order to stimulate the client's appetite? A. Reduce the frequency of meals in order to allow the client to develop an appetite. B. Offer nutritional supplements and explain the potential benefits of each. C. Offer larger meals and encourage the client to eat as much as is comfortable. D. Try to ensure that the client's food is attractive and sufficiently warm.

The nurse has provided teaching for a client with a sinus infection who has been prescribed antibiotics and a decongestant. The client states, "I'm not sure how many days I'm supposed to take this antibiotic." What is the nurse's appropriate response? A. Tell the client to take the antibiotic until symptoms subside. B. Ask the client to restate the teaching that was provided. C. Proceed with teaching about the decongestant. D. Reteach the length of time to take the prescription.

The nurse has recently been promoted to nurse manager on a pediatric unit and has decided to accept input from staff regarding changes they would like to see on the unit. Which type of leadership style is the nurse embodying? A. Quantum B. Autocratic C. Laissez-faire D. Democratic

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 attentive and responsive to the health care needs of individual clients and ensures the continuity of care when leaving these clients. What interpersonal skill is the nurse displaying? A. Developing technical skills B. Enjoying the rewards of mutual interchange C. Developing ethical/legal skills D. Developing accountability

The nurse is caring for a client whose treatment has been based on the Ayurveda medical system. Which nursing intervention incorporates this client's beliefs into the nursing plan? A. Preparing the client for exercises that help him or her regulate qi B. Including the client's shaman in the plan of care C. Basing practice on the yin-yang theory D. Helping the client to balance his or her dosha

The nurse is caring for a client with a knee sprain. Which client statement regarding use of an ice pack indicates that nursing teaching has been effective? A. "I must wait 5 minutes between cold therapy applications." B. "I will put this on my knee until it becomes numb." C. "I can keep this on my knee for 45 minutes at a time." D. "I will put a washcloth between my knee and the ice pack."

The nurse is caring for an underweight client diagnosed with a new food allergy to wheat, rye, and oats and with a nursing diagnosis of Imbalanced Nutrition: less than body requirements. What is the most appropriate intervention for this client? A. Administer a daily multivitamin B. Monitor for allergies C. Weigh client as needed D. Administer a 2,500-calorie (10,460-kJ) diet, excluding wheat, rye, and oats

The nurse is developing a plan of care for a client with a fractured femur who is in traction and will be restricted to bed for some time. Which domain should the nurse consider when developing a nursing diagnosis based on this client's musculoskeletal health problems? A. Nutrition B. Self-perception C. Health promotion D. Activity and rest

The nurse is educating a client regarding a new skill. When evaluating the client's knowledge about the topic covered, which best represents that the client has learned a new skill? A. The client nods when asked about process and assists with cleanup. B. The client states understanding and passes a written test. C. The client verbalizes items needed and how to perform the skill. D. The client organizes materials needed and gives return demonstration.

The nurse is preparing a client for surgery and asks if the client has an advance directive. The client asks "What is an advance directive?" What is the nurse's best response to this? A. "When you are going to have surgery, the hospital likes to have you fill out all paperwork needed beforehand." B. "An advance directive is a living will. Some people already have one when they come to the hospital." C. "We are not sure if you will wake up after surgery so the advance directive will let us know your wishes just in case." D. "An advance directive will communicate your wishes for health care postoperatively in case you are unable to do so."

The nurse is preparing to administer a large-volume enema to an adult client. How far should the nurse insert the tubing into the rectum? A. 2 in (5.0 cm) B. 5 in (12.5 cm) C. 1 in (2.5 cm) D. 3 in (7.5 cm)

The nurse is preparing to auscultate the bowel sounds of a client with a nasogastric tube in place set to low intermittent suction. How shall the nurse approach the assessment of bowel sounds and manage the nasogastric tube? A. Disconnect the nasogastric tube from the suction for 1 hour prior to the assessment of bowel sounds. B. Allow the low intermittent suction to continue during the assessment of bowel sounds. C. Apply continuous suction to the nasogastric tube during assessment of bowel sounds. D. Disconnect the nasogastric tube from suction during the assessment of bowel sounds.

The nurse is presenting a lecture on ostomy bowel elimination at a community clinic. When questioned by the clients, which food would the nurse suggest as natural intestinal deodorizers? A. Onions and garlic B. Fish and dried lentils C. Asparagus and turnip D. Yogurt and buttermilk

The nurse is providing care to a client whose condition has progressively declined. The nurse assesses and makes appropriate interventions as well as notifies the health care provider. Despite the nurse's efforts, the client expires. What element of liability has the nurse demonstrated? A. Damages B. Causation C. Breach of duty D. Duty

The nurse is providing education about deep-breathing exercises to a postoperative client whose surgery took place earlier today. Which instruction should the nurse provide? A. "It's best to do your exercises before a meal rather than after eating and drinking." B. "Take off your oxygen nasal prongs during your exercises and replace them as soon as you're done." C. "If possible, lie flat on your back while you're doing your breathing exercises." D. "Try to do your exercises every 1 to 2 hours."

The nurse is visiting a client who was released from inpatient rehabilitation 6 weeks ago after a 5-month recovery from a motor vehicle accident that left the client immobile. As the nurse enters the home, the client braces hands on the arms of a chair to rise and uses crutches to walk across the room. What is the best response by the nurse? A. "Those physical therapists work wonders. B. "Are you supposed to be out of the wheelchair?" C. "Let me document that you can walk." D. "You have made an amazing recovery."

The nurse manager in a critical care unit actively listens to the staff and engages the staff to offer decisions regarding problem solving and implementing these decisions. What type of managerial mindset does this manager exhibit? A. Action mindset B. Reflective mindset C. Analytical mindset D. Collaborative mindset

Two staff nurses on a unit disagree with one another over certain key aspects of providing client care. The nurse manager of the unit arranges a meeting with the charge nurse and the two staff nurses at a mutually agreed-upon time to discuss this situation. This activity is most accurately described as what? A. Client protection B. Delegation C. Problem solving D. Conflict resolution

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. Allowed the Jackson-Pratt drain to hang freely to avoid any kinks in the tubing. B. Apply an abdominal binder over the entire wound and drain to support the site. C. Tape the drain to the dressing material securely below the level of the wound. D. Secure the drain to the client's gown with a safety pin below the level of the wound.

When a multidisciplinary team is involved in meeting the home care needs of a client, who is the person responsible for the coordination of the care provided? A. The social worker B. The chaplain or minister C. The home health care aide D. The registered nurse

When obtaining information for a database, which of the following represents a nurse commitment and interest in reflected integrative medicine (CAM)? A. "Which types of foods do you consume in 24 hours?" B. "Which prescription medications do you take daily?" C. "Which diseases do you suffer from and what are your allergies?" D. "Do you take any vitamins or minerals, and if so, what?"

When preparing a client who has diabetes mellitus for surgery, the nurse should be aware of what surgical risk associated with this disease? A. altered metabolism and excretion of drugs B. fluid and electrolyte imbalance C. respiratory depression from anesthesia D. slow wound healing

Which action constitutes battery? A. The nurse threatens to restrain a client if the client does not take a medication. B. While bathing a client behind pulled curtains, two nurses discuss a different client. C. The nurse tells a client that the client cannot leave the hospital because the client is seriously ill. D. An older adult client refuses an intramuscular injection, but the nurse administers it.

Which activity is the clearest example of the evaluation step in the nursing process? A. Recognizing that the client's blood pressure of 172/101 is an abnormal finding B. Taking a client's blood pressure on both arms at the beginning of a shift C. Giving the client an as-needed dose of captopril in light of an abnormal blood pressure reading D. Checking the client's blood pressure 30 minutes after administering captopril

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

Which government policy addresses penalizing hospitals for readmissions of clients with certain diagnoses within 30 days after discharge? A. American Nurses Association Bylaws B. Americans with Disabilities Act C. National Commission for Minorities D. Affordable Care Act

Which is a characteristic of a person-centered or helping relationship? A. Spontaneous occurrence with random individuals B. A focus on the needs of the helping person C. The accountability of the person being helped for the outcomes of the relationship D. An unequal sharing of information

Which is an example of an unintentional tort? A. A nurse tells a client that the client cannot leave the hospital until the client pays the bill. B. A nurse threatens to restrain a client if the client does not stop talking. C. Nurses discuss a client's laboratory values in the elevator. D. A nurse gives the client a medication, and the client has an adverse reaction to it.

Which is the most appropriate example of the assessment phase of the nursing process? A. Including a nursing diagnosis of Acute Pain in the client's plan of care B. Evaluating the temperature of a client given medication for a fever C. Documenting the administration of a medication provided for pain D. Palpating a mass in the right lower quadrant of the abdomen

Which nursing action associated with successful tube feedings follows recommended guidelines? A. Prevent contamination during enteral feedings by using an open system. B. Check tube placement by adding food dye to the tube feed as a means of detecting aspirated fluid. C. Assess for bowel sounds at least 4 times per shift to ensure the presence of peristalsis and a functional intestinal tract. D. Check the residual before each feeding or every 4 to 8 hours during a continuous feeding.

Which of these assessment findings indicate a positive outcome for a client after acupuncture? A. The client has improved balance and coordination. B. The client has increased his or her flexibility and strength. C. The client has lost 8 lb (3.63 kg) over the last 2 months. D. The client reports a reduction in pain level to 3 out of 10.

Which of these statements reflects the expected functioning at a hospital that has achieved Magnet status? A. There is a decreased rate of retention among the nursing staff. B. Most client outcomes have improved but are not at target range. C. Nursing administration is in control of all decision-making. D. Staff nurses are developing innovative solutions to problems.

Which surgical client does the nurse in the preoperative setting anticipate having the greatest potential for surgical complications? A. 40-year-old client with type 2 diabetes mellitus and a history of anxiety B. 50-year-old overweight client with controlled hypertension C. 6-month-old client who has just been introduced to solid food D. 76-year-old client with a history of renal failure and chronic bronchitis

Which type of facility employs the greatest number of nurses? A. Primary care centers B. Long-term care facilities C. Ambulatory care centers D. Hospitals

A charge nurse on a medical-surgical unit is asked by the nurse manager to serve as a mentor to another staff nurse who is less experienced. Which of these would best describe this role? A. The charge nurse is providing support for the staff nurse in new responsibilities. B. The charge nurse is being paid to supervise the staff nurse. C. The staff nurse is learning about all the hospital policies from the charge nurse. D. The staff nurse is orienting to the unit as a newly hired nurse.

A nurse is discussing vitamin supplementation. Which groups are more prone to mild vitamin deficiencies? Select all that apply. A. Pregnant or lactating women B. Middle-age adults C. Strict vegetarians D.Non-smokers E. Adolescents

A, C, E,

What type of dressing has the advantage of remaining in place for three to seven days, resulting in less interference with wound healing? A. hydrocolloid dressing B. hydrogel C. alginate D. transparent film

A 2-year-old toddler just underwent a tonsillectomy and adenoidectomy surgery. The postanesthesia care unit (PACU) nurse is checking on him. What is the best course of action regarding the developmental care of this child? A. Allow the parents into the PACU before the child wakes. B. Administer acetaminophen before the child wakes. C. Give the child a new teddy bear. D. Extubate the child as soon as possible.

When assessing a client's nonverbal communication, the nurse should assess which aspect as being the most expressive? A. Facial expressions B. Hand gestures C. Posture D. Eye contact

When reviewing a client's chart, which data related to a client experiencing diarrhea might suggest to the nurse a causative factor? A. The client returned from a foreign country 2 days ago. B. The client has a daily fluid intake of 2,000 to 3,000 mL. C. The client repeatedly ignores the urge to defecate. D. The client consumes large qualities of fresh vegetables.

The nurse is collecting health data and avoids using closed-ended questions. Which are examples of closed-ended questions? Select all that apply. A. "Is there any chance you might be pregnant?" B. "Does it hurt when I touch you here?" C. "Do you smoke cigarettes?" D. "Are you ready to get out of bed?" E. "What plans do you have after you are discharged?" F. "What sorts of things do you do for fun?"

A, B, C, D

Which client(s), at risk for poor nutritional intake, would benefit from nutritional counseling from the nurse? Select all that apply. A. older adults living on fixed incomes B. individuals who prefer to purchase food from local farmers c. pregnant teenagers d. children of middle-income parents E. people with substance use problems

A, C, E

A nurse is communicating the plan of care to a client who is cognitively impaired. Which nursing actions facilitate this process? Select all that apply. A. The nurse maintains eye contact with the client. B. The nurse gives lengthy explanations of the care that will be given. C. The nurse shows patience with the client and gives the client time to respond. D. The nurse communicates in a busy environment to hold the client's attention. E. If there is no response, the nurse does not repeat what is said and takes a break. F. The nurse keeps communication simple and concrete.

A, C, F

A nurse has completed a client assessment and is preparing to identify appropriate nursing diagnoses. Which areas would the nurse likely address in the diagnosis? Select all that apply. A. Impaired mobility B. Heart failure C. Pneunomia D. Imbalanced nutrition E. Ineffective coping

A, D, E

A 56-year-old client meets with the nurse for education about a recently diagnosed atrial fibrillation. The client verbalizes concerns about being away from work too long and doubts about the necessity of having blood tests every week, as the client has no symptoms. Which is the best motivational statement by the nurse for this client? A. "You have to take your warfarin and go to the clinic every week for a blood draw. It's not the most convenient way to live, but you have to do it." B. "The medicine and blood work can help prevent blood clots, which can lead to strokes. What do you know about warfarin therapy?" C. "Atrial fibrillation is when your upper heart beats ineffectively and blood clots can go to your brain. Would you like some printed information about this?" D. "Your doctor wants you to take your warfarin every day, go to the clinic every week to have blood drawn, and then wait for any dosage change. Do you understand?"

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first? A. Administer the prescribed analgesic. B. Assess the client's wound and vital signs. C. Notify the health care provider of the pain. D. Document the pain and vital signs.

The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing? A. Banana B. Fish C. Green beans D. Pasta salad

Which of the following is a fat-soluble vitamin? A. vitamin C B. vitamin E C. vitamin B6 D. vitamin B12

Which term refers to a purposeful activity that leads to action, improvement of practice, and better client outcomes? A. Assessment B. Reflection C. Evaluation D. Memorization

A 16-year-old adolescent informs her nurse that she became a vegetarian 1 year ago. Lately she is reporting fatigue and has trouble concentrating. A quick blood test ordered by her licensed provider informs the nurse that she has pernicious anemia. This is a deficiency of what vitamin? A. vitamin A B. vitamin C C. vitamin B12 D. folic acid

A 16-year-old client has been injured in an accident and is receiving home care due to fractures and multiple trauma-related injuries. The client states, "I don't know why I survived and not my best friend." It is most important for the home care nurse to encourage the client to: A. increase the client's activity to assist in coping. B. be certain that the client's educational needs are being met. C. communicate these feelings to family and friends. D. allow a religious leader in the client's life to visit.

A client arrives at the emergency department after experiencing several black, tarry stools. The nurse should assess for the cause of the client's complaint by: A. insisting that the client not eat or drink anything until further instructed. B. determining whether the client has any food or drug allergies. C. asking the client whether the client has recently taken ferrous sulfate (iron) or bismuth subsalicylate. D. asking the client to provide a stool specimen for guaiac testing.

Which client would a nurse correctly refer to Medicare services? A. A client with a disability B. A client with cancer C. A 66-year-old client with diabetes D. A low-income family with infants needing immunizations

A registered nurse is delegating activities to unlicensed assistive personnel (UAP) on a hospital unit. Which activities could this nurse normally delegate? Select all that apply. A. The determination of a nursing diagnosis for a client with breast cancer B. Planning education for a client with a colostomy C. Taking routine vital signs D. Transferring a client to another floor E. Administering medications to clients F. Giving a bed bath to a client

C, D, F

Which are characteristics of a critical thinker? Select all that apply. A. Acting like a know-it-all B. Accepting the status quo C. Resisting easy answers to client problems D. Thinking outside the box E. Thinking based on the opinions of others F. Being open to all points of view

C, D, F

Which nursing interventions reflect the accurate use of heat or cold during wound care? Select all that apply. A. The nurse instructs the client to lean or lie directly on the heating device. B. The nurse places a heating pad on a sprained wrist that is in the acute stage. C. The nurse covers a cold pack with a cotton sleeve to keep it in place on an arm. D. The nurse fills an ice bag with small pieces of ice to about two-thirds full. E. The nurse applies moist cold to a client's eye for 40 minutes every 2 hours. F. The nurse makes more frequent checks of the skin of an older adult using a heating pad.

C, D, F

A nurse is providing teaching to clients in a short-term rehabilitation facility. Which examples are common teaching mistakes made by health care professionals? Select all that apply. A. The nurse evaluates what the client has learned. B. The nurse negotiates goals with the client. C. The nurse fails to accept that clients have the right to change their minds. D. The nurse reviews educational media when planning learner objectives. E. The nurse uses medical jargon frequently when discussing the teaching plan. F. The nurse ignores the restrictions of the client's environment.

C, E, F

A 70-year-old client had a cholecystectomy 4 days ago. The client's daughter tells the nurse, "My mother seems confused today." Which question would be best for the nurse to ask to assess the client's orientation? A. "Is your name Evelyn?" B. "Is today the first day of the month?" C. "Are you in a hospital?" D. "What day of the week is it?"

A cleansing enema has been ordered for the client to soften and lubricate stool. Which type of solution does the nurse gather? A. tap water B. hypertonic saline C. soap and water D. mineral oil

A client is received into the emergency department after getting shot in the chest. The client is hemorrhaging profusely and is in hypovolemic shock. The nurse calls a code blue. What type of leadership style will be most effective during the management of the code? A. Laissez-faire leadership B. Democratic leadership C. Transactional leadership D. Autocratic leadership

A client who is receiving chemotherapy and experiencing significant nausea asks the nurse about using aromatherapy to help alleviate the nausea. Which essential oil would the nurse most likely suggest to address the client's nausea? A. Chamomile B. Cedarwood C. Lavender D. Ginger

Care provided to a client following surgery and until discharge represents which phase of the nurse-client relationship? A. Termination phase B. Orientation phase C. Evaluation phase D. Working phase

Which is the primary criterion for admission to a long-term care facility? A. Coexistence of multiple chronic health problems B. Advanced age C. Absence of family members locally D. Inability to provide self-care

Which principle does not encompass the basic goals of integrative medicine? A. Establish a partnership between client and practitioner. B. Facilitate the body's innate healing abilities. C. Focus on promoting health and preventing illness, as well as treating disease. D. Reject allopathic medicine and embrace CAM practices.

Which statement regarding critical thinking in nursing is true? A. It makes judgments based on conjecture. B. It supplies validation for reimbursement. C. It shows trends and patterns in client status. D. It is a systematic way of thinking.

Which strategy should the nurse use when providing education to the older adult client? A. Teach from books only and remain calm. B. Avoid the use of colorful materials and keep the session short. C. Teach in a monotone voice in a quiet environment. D. Remain calm and conduct the teaching session in a quiet environment.

Which statements made by the nurse acknowledge the client as a human being? Select all that apply. A. "I am going to cleanse your back; turn over for me, sweetie." B. "Hi Tom. Please take your clothes off and put this gown on with the opening in the back." C. "Honey, can you tell me why you are crying?" D. "I have your medications ready for you, Ms. Jackson." E. "Hey buddy, how was your night last night?" F. "Mr. Smith, I will be taking you to x-ray now."

D, F

A lawyer is describing the litigation process to a nurse named in a malpractice lawsuit. Which statements by the lawyer accurately describe this process? Select all that apply. A. "We will start litigation in the first-level court known as the appellate court." B. "As the defendant, you will be presumed guilty until proven innocent." C. "The defendant is the person who is initiating the lawsuit." D. "Common law is based on the principle of stare decisis." E. "The process of bringing and trying this lawsuit is called litigation." F. "The opinions of appellate judges are published and become common law."

D,E,F

The nurse is preparing to insert a nasogastric (NG) tube into an adult client. Place the following steps in the correct order. Use all options. A. Direct the tube upward and backward along the floor of the nose. B. Advance the tube while the client swallows. C. Instruct the client to place the chin onto the chest. D. Measure the intended length to insert the NG tube. E. Place the client in high Fowler's position. F. Lubricate the tube tip with water-soluble lubricant.

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