Basics of Nursing Practice

According to Kübler-Ross, during which stage of grieving are individuals with serious health problems most likely to seek other medical opinions? 1.Anger 2.Denial 3.Bargaining 4.Depression

2.Denial

The nurse recognizes that what is the reason the faucets on the sinks in a client's room are considered contaminated? 1.They are not in sterile areas. 2.They are touched by dirty hands when turning the water on. 3.There are large numbers of people who use them each day. 4.Water encourages bacterial growth.

2.They are touched by dirty hands when turning the water on.

The nurse is caring for an older adult client who is aphasic. The client's family reports to the nurse manager that the primary nurse failed to obtain a signed consent form before inserting an indwelling catheter to measure intake and output. What should the nurse manager consider before responding? 1.Procedures for a client's benefit do not require a signed consent. 2.Clients who are aphasic are incapable of signing an informed consent. 3.A separate signed informed consent for routine treatments is unnecessary. 4.A specific intervention without a client's signed consent is an invasion of rights.

3.A separate signed informed consent for routine treatments is unnecessary.

The nurse plans care for a client with a somatoform disorder based on the understanding that the disorder is: 1.A physiological response to stress. 2.A conscious defense against anxiety. 3.An intentional attempt to gain attention. 4.An unconscious means of reducing stress

4.An unconscious means of reducing stress

While the nurse moves a client from a lying to standing position, the client experiences a rapid drop in blood pressure. The nurse would report this finding as: 1.malignant hypotension 2.orthostatic dehydration 3.orthostatic hypotension 4.vasomotor instability

3.orthostatic hypotension

A nurse is teaching a group of parents about child abuse. What definition of assault should the nurse include in the teaching plan? 1.Assault is a threat to do bodily harm to another person. 2.It is a legal wrong committed by one person against the property of another. 3.It is a legal wrong committed against the public that is punishable by state law. 4.Assault is the application of force to another person without lawful justification.

1.Assault is a threat to do bodily harm to another person.

Nurses care for clients in a variety of age groups. In which age group is the occurrence of chronic illness the greatest? 1.Older adults 2.Adolescents 3.Young children 4.Middle-aged adults

1.Older adults

What should the nurse consider when obtaining an informed consent from a 17-year-old adolescent? 1.If the client is allowed to give consent. 2.The client cannot make informed decisions about health care. 3.If the client is permitted to give voluntary consent when parents are not available. 4.The client probably will be unable to choose between alternatives when asked to consent

1.If the client is allowed to give consent.

On the third postoperative day following a below-the-knee amputation, a client is refusing to eat, talk, or perform any rehabilitative activities. What is the best initial approach that the nurse should take when interacting with this client? 1.Explain why there is a need to increase activity. 2.Emphasize that with a prosthesis, there will be a return to the previous lifestyle. 3.Appear cheerful and non-critical regardless of the client's response to attempts at intervention. 4.Acknowledge that the client's withdrawal is an expected and necessary part of initial grieving

4.Acknowledge that the client's withdrawal is an expected and necessary part of initial grieving

What should a nurse recommend to help a client best during the period immediately after a spouse's death? 1.Crisis counseling 2.Family counseling 3.Marital counseling 4.Bereavement counseling

4.Bereavement counseling

A client has a "prayer cloth" pinned to the hospital gown. The cloth is soiled from being touched frequently. What should the nurse do when changing the client's gown? 1.Make a new prayer cloth. 2.Discard the soiled prayer cloth. 3.Pin the prayer cloth to the clean gown. 4.Wash the prayer cloth with a detergent

3.Pin the prayer cloth to the clean gown.

The nurse should place the client in which position to obtain the most accurate reading of jugular vein distention? 1.Upright at 90 degrees 2.Supine position 3.Raised to 45 degrees 4.Raised to 10 degrees

3.Raised to 45 degrees

A nurse is reinforcing teaching to an adolescent about type 1 diabetes and self-care. Which questions from the client indicate a need for additional teaching in the cognitive domain? (Select all that apply.) 1."What is diabetes?" 2."What will my friends think?" 3."How do I give myself an injection?" 4."Can you tell me how the glucose monitor works?" 5."How do I get the insulin from the vial into the syringe?

1."What is diabetes?" 4."Can you tell me how the glucose monitor works?"

On the second day of hospitalization a client is discussing with the nurse concerns about unhealthy family relationships. During the nurse-client interaction the client begins to talk about a job problem. The nurse's response is: "Let's go back to what we were just talking about." What therapeutic communication technique did the nurse use? 1.Focusing 2.Restating 3.Exploring 4.Accepting

1.Focusing

A 3-year-old child with eczema of the face and arms has disregarded the nurse's warnings to "stop scratching, or else!" The nurse finds the toddler scratching so intensely that the arms are bleeding. The nurse then ties the toddler's arms to the crib sides, saying, "I'm going to teach you one way or another." How should the nurse's behavior be interpreted? 1.These actions can be construed as assault and battery. 2.The problem was resolved with forethought and accountability. 3.Skin must be protected, and the actions taken were by a reasonably prudent nurse. 4.The nurse had tried to reason with the toddler and expected understanding and cooperation

1.These actions can be construed as assault and battery.

A physician orders a urinalysis for a client with an indwelling catheter. To ensure that an appropriate specimen is obtained, the nurse would obtain the specimen from which site? 1.tubing injection port 2.distal end of the tubing 3.urinary drainage bag 4.catheter insertion site

1.tubing injection port

When changing the soiled bed linens of a client with a wound that is draining seropurulent material, what personal protective equipment (PPE) is most essential for the nurse to wear? 1.Mask 2.Clean gloves 3.Sterile gloves 4.Shoe covers

2.Clean gloves

A client is admitted to the hospital for an elective surgical procedure. The client tells a nurse about the emotional stress of recently disclosing being a homosexual to family and friends. What is the nurse's first consideration when planning care? 1.Exploring the client's emotional conflict 2.Identifying personal feelings toward this client 3.Planning to discuss this with the client's family 4.Developing a rapport with the client's health care provider

2.Identifying personal feelings toward this client

A nurse is providing morning hygiene to a bedridden client who was admitted for exacerbation of chronic obstructive pulmonary disease (COPD). What is the priority nursing intervention when the client becomes short of breath during the care? 1.Obtain a pulse oximeter to determine the client's oxygen saturation level. 2.Put the client in a high-Fowler's position. 3.Darken the lights and provide a rest period of at least 15 minutes. 4.Continue the hygiene activities while reassuring the client

2.Put the client in a high-Fowler's position.

A client who is HIV positive is admitted to a surgical unit after an orthopedic procedure. The nurse should institute appropriate precautions with the awareness that HIV is highly transmissible through: (Select all that apply.) 1 .feces 2.blood 3.semen 4.urine 5.sweat 6.tears

2.blood 3.semen

A daughter of a Chinese-speaking client approaches a nurse and asks multiple questions while maintaining direct eye contact. What culturally related concept does the daughter's behavior reflect? 1.Prejudice 2.Stereotyping 3.Assimilation 4.Ethnocentrism

3.Assimilation

The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer's dementia. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen the client is to take medications six times throughout the day. What is priority nursing intervention to assist the client with compliance with medication-taking? 1.Contact the client's children and ask them to hire a private duty aide who will provide round-the-clock care. 2.Develop a chart for the client, listing the times the medication should be taken. 3.Contact the primary healthcare provider and discuss the possibility of simplifying the medication regimen. 4.Instruct the client and client's children to put medications in a weekly pill organizer

3.Contact the primary healthcare provider and discuss the possibility of simplifying the medication regimen.

A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. This assessment should be documented as: 1.Vesicular 2.Bronchial 3.Crackles 4.Rhonchi

3.Crackles

A client with respiratory difficulties asks why the percussion procedure is being performed. The nurse explains that the primary purpose of percussion is to: 1.Relieve bronchial spasm. 2.Increase depth of respirations. 3.Loosen pulmonary secretions. 4.Expel carbon dioxide from the lungs.

3.Loosen pulmonary secretions.

A nurse fails to act in a reasonable, prudent manner. Which legal principle is most likely to be applied? 1.Malice 2.Tort law 3.Malpractice 4.Case law

3.Malpractice

A senior high school student, whose immunization status is current, asks the school nurse which immunizations will be included in the precollege physical. Which vaccine should the nurse tell the student to expect to receive? 1.Hepatitis C (HepC) 2.Influenza type B (HIB) 3.Measles, mumps, rubella (MMR) 4.Diphtheria, tetanus, pertussis (DTaP)

3.Measles, mumps, rubella (MMR)

A nurse is teaching staff members about the legal terminology used in child abuse. What definition of battery should the nurse include in the teaching? 1.Maligning a person's character while threatening to do bodily harm. 2.A legal wrong committed by one person against property of another. 3.The application of force to another person without lawful justification. 4.Behaving in a way that a reasonable person with the same education would not

3.The application of force to another person without lawful justification.

The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this indicates the pulse is: 1.diminished 2.normal 3.full 4.bounding

3.full

A terminally ill client is furious with one of the staff nurses. The client refuses the nurse's care and insists on doing self-care. A different nurse is assigned to care for the client. What should be the newly assigned nurse's initial step in revising the client's plan of care? 1.Get a full report from the first nurse and adjust the plan accordingly. 2.Ask the health care provider for a report on the client's condition and plan appropriately. 3.Tell the client about the change in staff responsibilities and assess the client's reaction. 4.Assess the client's present status and include the client in a discussion of revisions to the plan of care

4.Assess the client's present status and include the client in a discussion of revisions to the plan of care

Which action by a home care nurse would be considered an act of euthanasia? 1.Implementing a "do not resuscitate" order in the home health setting. 2.Abiding by the decision of a living will signed by the client's family. 3.Encouraging a client to consult an attorney to document and assign a power of attorney. 4.Knowing that a dying client is overmedicating and not acting on this information

4.Knowing that a dying client is overmedicating and not acting on this information