CORE MOD 4 PRACTICE Q'S:

A 20-year-old client with Down syndrome is diagnosed with an illness. Even though the client is able to live in an assisted environment and work part-time for a local bookstore, the parents of the client are adamant about not initiating a course of treatment whose side effects are unknown with Down syndrome clients. According to the nursing code of ethics, to whom is the nurse's first loyalty? 1. The client 2. The parent 3. The physician 4. The nurse

1

The nurse is caring for a client diagnosed with early osteoporosis. Which intervention is most applicable for this client? 1. Institute an exercise plan that includes weight-bearing activities. 2. Increase the amount of calcium in the client's diet. 3. Protect the client's bones with strict bed rest. 4. Provide the client with assisted range-of-motion exercising twice daily.

1

The nurse is caring for a client with a urinary diversion. For which type of diversion should the nurse plan care for this client? 1. Incontinent urinary diversion 2. The kock pouch. 3. Neobladder 4. Nephrostomy

1

The nurse is concerned that a client is at risk for the development of urinary tract infections. What did the nurse assess to come to this conclusion? 1. The client is wearing tight clothing. 2. The client is employed as a computer operator. 3. The client drinks 8-10 8-ounce glasses of water and low-calorie beverages each day. 4. The client exercises for 30-60 minutes most days of the week.

1

The nurse is considering using the NANDA nursing diagnosis Impaired Physical Mobility in the care plan of a newly admitted client. In order to make this problem statement more individual, the nurse should take which action? 1. Include what mobility is impaired. 2. Use Level 1, 2, 3, or 4 to describe immobility. 3. Describe what happens when the client attempts mobility. 4. Add strength assessment data.

1

The nurse is planning interventions for a client who has difficulty falling asleep. Which intervention regarding sleep times would be most helpful? 1. Maintain a regular bedtime and wake-up time for all days of the week. 2. If bedtime is delayed on one night, go to bed that much earlier the next night. 3. If daytime drowsiness occurs, go to bed earlier that night. 4. Sleep at least 1 hour later on mornings you don't have to go to work.

1

The nurse is preparing to assist a client to a lateral position to position a bedpan. What action should the nurse take first? 1. Perform hand hygiene. 2. Move the client to the side of the bed. 3. Place the client's arm over the chest. 4. Raise the opposite side rail.

1

The nurse is preparing to transfer a client from the bed to a stretcher. The correct position for the bed to be placed is parallel to the stretcher and 1. slightly higher. 2. slightly lower. 3. at the same height. 4. at least 2 inches lower.

1

The nurse learns that a home care client is diluting prescribed nutritional supplements because of the cost. What should the nurse do to advocate for this client? 1. Help the client look for available community resources that may be of assistance. 2. Tell the client that she needs to take the prescribed amount. 3. Report the situation to the physician. 4. Weigh the client on a weekly basis to monitor weight gain or loss.

1

The nurse needs to insert an intravenous access device into a toddler who is crying and scared. The parent asks if the procedure is painful. When practicing veracity, what should the nurse respond to the parent? 1. "I won't lie to you. It may be easier for you if you step out until we get the line in." 2. "We'll take every care not to hurt your child." 3. "It shouldn't be too bad and I'll be quick." 4. "We do this all the time, so don't worry."

1

The nurse wants to delegate the application of a condom catheter to unlicensed assistive personnel (UAP). What must the nurse assess prior to delegating this task? 1. Assess whether the client has unique needs. 2. Measure the client's intake. 3. Assist the client out of bed to a chair. 4. Assess changes in the client's mobility status.

1

The parents of a 6-month-old tell the nurse that they are exhausted because their baby wakes up several times every night. What advice should the nurse give these parents? 1. Be certain that the baby is truly awake before picking him up for feeding. 2. Let the baby "cry it out" for a few nights until he can sleep through the night. 3. Continue to respond to the baby whenever he is restless during the night. 4. Bring the baby in for a possible sleep study to check for sleeping disorders.

1

When planning care, the nurse should identify which client as needing logrolling for position changes? 1. A client with documented pneumonia 2. The client who has had abdominal surgery 3. The client who fell from a house, sustaining a fractured tibia 4. A client who has a severe headache from hypertensive crisis

1

Which goals should the nurse identify as appropriate for a client with the nursing diagnosis Urinary Pattern Alteration related to an enlarged prostate? 1. The client will avoid bladder distention. 2. The client will maintain fluid imbalance. 3. The client will remain free of skin breakdown. 4. The client will voice increased discomfort.

1

A client tells the nurse about having problems falling and staying asleep. What should the nurse ask the client to gain more information about this client problem? Standard Text: Select all that apply. 1. "How often does this happen?" 2. "How much coffee do you drink each day?" 3. "How do you feel when you wake up in the morning?" 4. "When do you eat your evening meal?" 5. "What have you done to deal with this sleeping problem?"

1,2,3,5

A client is having issues with urinary elimination. What should the nurse instruct this client to promote urinary elimination? 1. Don't interrupt your day by going to the bathroom; wait until you're at a good stopping place. 2. Drink 8 to 10 glasses of water daily. 3. Urine color changes are not important. 4. Wash with soap and water every other day.

2

A client is prescribed propranolol (Inderal). What should the nurse instruct the client about this medication? 1. The medication should be discontinued abruptly. 2. Notify the physician if you experience urinary retention. 3. Take a laxative every day. 4. Take the medication on an empty stomach.

2

A client complains of not being able to stay awake during the day even after sleeping throughout the night. What should the nurse suggestion to this client? 1. Go to your physician for a physical examination. 2. Go to a mental health professional for evaluation of possible depression. 3. Purchase an over-the-counter sleep aid to deepen nighttime sleep. 4. Drink more caffeinated beverages in the daytime to stay awake.

1

A client has a spinal cord injury at the cervical spine area. The nurse realizes that this injury will affect which aspect of urinary elimination in the client? 1. Elimination of urine from the bladder 2. Ability of the kidneys to absorb solutes 3. Ureteral function 4. Urethra function

1

The nurse is admitting a critically ill client to the intensive care unit. What question should the nurse ask regarding this client's sleep history? 1. No questions should be asked. 2. "When do you usually go to sleep?" 3. "Do you have any problems with sleeping?" 4. "What are your bedtime rituals?"

1

The nurse is assessing a client's urinary elimination. Which factor should the nurse keep in mind as influencing this elimination? 1. Age 2. Body image 3. Knowledge 4. Socioeconomic status

1

A client has chosen to discontinue hemodialysis. His family is not supportive of his decision. Which statement should the nurse make that demonstrates the theory of principles-based reasoning? 1. "This client is of sound mind and is capable of making his own decisions regarding health care. It really is his decision to make." 2. "I need to try and help the family understand the client's decision so they can work through this situation together." 3. "This client's health is so deteriorated that the treatment is not saving his life. It is prolonging the ultimate outcome, which is his death." 4. "The client understands his decision and the advanced stage of his disease. If he quits treatment, he will die."

1

A client is rushed to the emergency department with what the physicians suspect to be necrosis of the urinary diversion stoma. What evidence presented by the client leads to this conclusion? 1. Black with sloughing 2. Moist stoma 3. Pink and shiny 4. Slight bleeding from stoma

1

A client reports the need to urinate during the night and then not being able to fall back asleep. The nurse should document this assessment finding as which factor that influences sleep? 1. Illness 2. Stimulant 3. Diet 4. Lifestyle

1

A client tells the nurse about the need to get up several times throughout the night to void. The nurse suspects the client is experiencing nocturia due to which factor? 1. Decrease in bladder tone 2. Decrease in blood supply 3. Decrease in number of nephrons 4. Decrease in cardiac output

1

A client with diabetes asks the nurse why his blood glucose level is higher on days when he sleeps less. What should the nurse explain to the client? 1. During sleep, the hormone cortisol is inhibited. If sleep is interrupted, cortisol levels will remain elevated, impacting blood glucose. 2. Because the client is awake more, it is likely the client is eating more, which is impacting the blood glucose level. 3. There is no relationship between sleep and blood glucose levels. 4. The body needs cortisol for the extra energy created by the lack of sleep.

1

An older adult fell at home and fractured a hip, which requires surgical repair. After admittance to the emergency department, the client was given sedation for pain before a surgical permit was signed. What should be done to obtain consent? 1. The physician should have the client's wife sign the consent form. 2. The physician should wait until the effects of the medication wear off and have the client sign the form. 3. Because the client has been medicated, the nurse should thoroughly explain the consent form to the client. 4. This would be considered an emergency situation and consent would be implied.

1

The admitting nurse explains the process of signing forms to allow for the client's insurance company to be billed for services. If the insurance fails to pay for services, the client is responsible for payment. Which type of law did the nurse explain to the client? 1. Contract law 2. Tort law 3. Statutory law 4. Administrative law

1

The client has been prescribed zolpidem (Ambien) for the short-term management of insomnia. What information should the nurse include when teaching the client about this medication? 1. For best results, take the medication just prior to bedtime. 2. Take the medication at dinnertime to avoid gastric upset. 3. Do not take the medication with any liquid that contains calcium. 4. Drink an entire glass of water with the dose to avoid kidney stones.

1

The client reports difficulty sleeping and awakening several times during the night. What intervention should the nurse recommend for the client when unable to sleep? 1. Get out of bed, go into another room, and pursue some relaxing activity until drowsy. 2. Get out of bed, go into another room, and exercise until tired before trying to go back to sleep. 3. Sit in bed and watch the bedroom television until drowsy. 4. Stay in bed with eyes closed and do some mental arithmetic until sleepy.

1

The client who is unconscious is developing foot drop. What nursing action is indicated? 1. Place high-topped shoes on the client while in bed. 2. Keep the linens on the end of the bed turned back to expose the feet. 3. Use only the prone and Sims positions for client positioning. 4. Use a device to elevate the linens off the feet.

1

The high school graduate desiring to attend nursing school reviews the schools for accreditation. Which regulatory body's actions is the student analyzing? 1. State board of nursing 2. NLNAC 3. CCNE 4. ANA

1

The nurse has documented that the client has orthostatic hypotension. Which assessment finding would support this assessment? 1. Decrease in blood pressure when moving from supine to standing 2. Decrease in heart rate when moving from supine to sitting 3. Pale color in the legs when lying in bed 4. Complaints of dizziness when first sitting up

1

The nurse is completing the admission assessment on a client who has obstructive sleep apnea. Which findings should the nurse expect when assessing this client? Standard Text: Select all that apply. 1. Reddened uvula 2. Large soft palate 3. Obesity 4. Short neck 5. Deviated septum

1,2,3

A client has not had uninterrupted sleep for several nights, and is irritable. What other assessment findings should the nurse associate with the client's lack of REM sleep? Standard Text: Select all that apply. 1. Depression 2. Confusion 3. Disorientation 4. Impaired memory 5. Muscle weakness

1,2,3,4

The nurse suspects that an adult is not getting an adequate amount of nightly sleep. What information caused the nurse to have this suspicion? Standard Text: Select all that apply. 1. Enrolled in online classes 2. Raising two children ages 4 and 8 3. Experiences chronic pain from sciatica 4. Attends religious services every Sunday and Wednesday 5. Works one job steady night turn and another part-time late afternoon

1,2,3,5

The nurse is instructing a client on ways to manage stress urinary incontinence. What should be included in this client's teaching? Standard Text: Select all that apply. 1. Limit intake of caffeine. 2. Limit intake of alcohol. 3. Increase intake of citrus juices. 4. Limit evening fluid intake. 5. Increase intake of beverages with artificial sweeteners.

1,2,4

After an assessment, the nurse is concerned that an older client is experiencing changes in sleep. What findings did the nurse use to make this clinical decision? Standard Text: Select all that apply. 1. Is wide awake around 3 AM 2. Takes a nap after lunch every day 3. Returns to sleep after using the bathroom 4. Goes to sleep before 9 PM most evenings 5. Wakes up and looks at the clock every hour

1,2,4,5

The client has a history of postural hypotension. Which activities should the nurse advise this client as likely to cause postural hypotension? Standard Text: Select all that apply. 1. Hot baths 2. Heavy meals 3. Use of a rocking chair 4. Moving in bed 5. Bending down to the floor

1,2,5

The nurse is planning care for a client who has limited bed mobility. What instruction should be given to the assistive personnel who will be caring for this client? Standard Text: Select all that apply. 1. Place a turn sheet on the bed. 2. Always use two personnel to move the client. 3. Stand at the head of the bed to pull the client up. 4. Slide the client toward the head of the bed. 5. Encourage the client to assist as possible.

1,2,5

The nurse is reviewing the preamble of the International Council of Nurses Code of Ethics. On which responsibilities should the nurse focus when reviewing this preamble? Standard Text: Select all that apply. 1. Promote health. 2. Restore health. 3. Inform the public about minimum standards of nursing conduct. 4. Provide self-regulation in the profession. 5. Prevent illness. 6. Alleviate suffering.

1,2,5,6

A client is complaining of pain with urination. The nurse realizes that the client needs to be assessed for which health problems? Standard Text: Select all that apply. 1. Urethral stricture 2. Renal failure 3. Urethral injury 4. Bladder injury 5. Urinary infection

1,3,4,5

An older female client with a history of urinary tract infections has an indwelling urinary catheter. What should the nurse do to reduce this client's risk of developing an infection because of the catheter? Standard Text: Select all that apply. 1. Maintain a sterile closed drainage system. 2. Clean the peri-urethral area with antiseptics. 3. Ensure the catheter and tubing are not kinked. 4. Wash his or her hands before manipulating the catheter. 5. Keep the collection bag below the level of the bladder.

1,3,4,5

The school of nursing professor is preparing a classroom activity to assist the students in acquiring professional values. Which actions should the professor select for this assignment? Standard Text: Select all that apply. 1. Discuss codes of ethics with the students. 2. Recommend that the students avoid ethical issues. 3. Encourage the students to discuss experiences. 4. Invite other professors to participate in a discussion. 5. Have the students interview each other about experiences.

1,3,4,5

The nurse is documenting the insertion of a retention catheter for a client. What should be included in this documentation? Standard Text: Select all that apply. 1. Catheter size 2. Location of the drainage bag 3. Amount of urine that drained after insertion 4. Name of the physician who prescribed the insertion of the catheter 5. Client tolerance of the procedure

1,3,5

The nurse is addressing an ethical issue. In which order should the nurse implement the steps of this decision-making process? Standard Text: Click and drag the options below to move them up or down. Choice 1. Interviewing the client regarding details of the problem Choice 2. Discussing the various results of the identified possible actions to resolve the problem Choice 3. Determining what, if any, ethical issues exist Choice 4. Determining whether affected parties are in ethical conflict Choice 5. Assessing all involved parties concerning their ethical beliefs regarding the problem

1,3,5,4,2

A client's urine pH is 8.0. What further assessments would be indicated for this client? Standard Text: Select all that apply. 1. Intake of fruits and vegetables 2. Intake of cranberries 3. Intake of high-protein foods 4. Symptoms of diarrhea 5. Symptoms of a urinary tract infection

1,5

A client has been admitted with incontinence. What should the nurse expect to assess in this client? 1. Client is wearing cotton undergarments. 2. Leakage of urine occurs when client laughs. 3. Leakage of urine occurs when talking with the client. 4. The skin of the client is clear without discoloration.

2

A client has been complaining of pain, even though the nurse has given the client the maximum amount of medication as ordered by the physician. Which action demonstrates the nurse's respect for the client's autonomy? 1. Telling the client that he will have to "tough it out" 2. Calling the physician for further orders 3. Telling co-workers that this client has no pain tolerance 4. Believing the client is drug seeking

2

A client questions why a medication that is used to treat Parkinson's disease has been prescribed for the diagnosis of periodic limb movement disorder (PLMD). What should the nurse do? 1. Contact the physician. 2. Assure the client that medications used to treat Parkinson's disease are also used to treat PLMD. 3. Tell the client not to take the medication because there is most likely an error. 4. Check with the pharmacy to make sure the correct medication has been provided to the client

2

A client recovering from a transurethral resection of the prostate (TURP) with a three-way indwelling catheter expresses the need to urinate. Which action should the nurse take to help this client? 1. Deflate and then reinflate the balloon. 2. Irrigate the catheter. 3. Reposition the catheter. 4. Retape the catheter to the abdomen.

2

A client tells the nurse that because of work and life responsibilities, sleep has "become optional." What is the best response the nurse should make to this client? 1. "Be sure to get extra sleep when you can." 2. "A lack of sleep can affect hormone levels and bodily functions." 3. "Everyone has different needs for sleep to in order to function." 4. "You must be very productive."

2

A client who smokes cigarettes tells the nurse that sleep is light, and that he awakens easily. What should the nurse suggest to help this client with sleep? 1. Smoke no cigarettes 1 hour before sleep. 2. Smoke no cigarettes after the evening meal. 3. Limit the number of cigarettes smoked during the day. 4. Adjust to the lack of sleep, because those who smoke do not get sufficient sleep.

2

A hospice nurse has been working closely with a client who, on several occasions, has asked about guidance and support in ending her life. What information should the nurse use when making an ethical and moral decision about this client's request? 1. Passive euthanasia is an easy decision to arrive at. 2. Legal issues are not the same as moral or ethical ones. 3. Active euthanasia is supported in the Code for Nurses. 4. Assisted suicide is illegal in all states.

2

A nurse mistakenly gave a client who was NPO a morning breakfast tray. After realizing the mistake, the nurse notified the physician as well as the client; explained the consequences of this mistake, which included a delay in the client's scheduled procedure; and documented the situation in the client's medical record. What did this nurse demonstrate? 1. Altruism 2. Integrity 3. Social justice 4. Human dignity

2

A pregnant client says her main concern is that her baby will be born healthy, even though she admits to drinking alcohol on a regular basis. With what should the nurse realize this client is struggling? 1. Values transmission 2. Values clarification 3. Morals 4. Ethics

2

An adult client who cannot read needs surgery and is competent to make his own decisions. What is the best action that the nurse should take? 1. Tell the client in the nurse's own words what the surgical procedure involves. 2. Read the consent form to the client and have the client state understanding. 3. Make sure the physician explains the procedure to the client. 4. Have a family member who can read sign the consent form.

2

Parents of a terminally ill child have decided to remove their child from life support, a decision that has met with little positive support. Which nursing action demonstrates autonomy regarding the parents' decision? 1. Showing respect for the family 2. Respecting the parents' decision 3. Referring the parents to social services 4. Asking to be assigned to a different client

2

The client who is bed-bound complains of abdominal pain. Bowel sounds are present. What action should be taken by the nurse? 1. Percuss for flatness over the liver. 2. Palpate for bladder fullness. 3. Use the p.r.n. order to medicate the client with an antacid. 4. Inspect the sacral area for edema.

2

The mother of a newborn tells the nurse, "I am concerned about my baby. When she first goes to sleep, her eyes dart around under her eyelids, she doesn't breathe regularly, and she sometimes twitches." What advice should the nurse give this mother? 1. Please bring your baby in immediately for a checkup. 2. These are common behaviors in newborns and are normal. 3. You should ask the physician about these symptoms at your next checkup. 4. If your baby does this again, take her to the emergency department.

2

The nurse has completed closed irrigation of a client's retention catheter. What specific information should the nurse document about this procedure? 1. Number of ml of solution used to inflate the balloon of the catheter 2. Abnormal drainage, such as blood clots, pus, or mucous shreds 3. Location of the draining bag 4. Technique used to conduct the irrigation

2

The nurse is assisting a newly delivered mother in ambulating to the nursery to see the baby. The client complains of light-headedness and begins to faint. What is the nurse's most important action? 1. Ensure the client's modesty as she falls. 2. Be certain the client does not hit the head on anything. 3. Call for immediate assistance. 4. Check the vital signs and for excessive vaginal bleeding.

2

The nurse is caring for a client experiencing dyspnea. In which position should the nurse place this client? 1. High Fowler's position with two pillows behind the head 2. Orthopneic position across the overbed table 3. Prone position with knees flexed and arms extended 4. Sims position with both legs flexed

2

The nurse is developing a plan of care for a client diagnosed with narcolepsy. Which intervention should the nurse include in this plan of care? 1. Encourage the client to take an over-the-counter medication to improve nighttime sleep. 2. Be certain the client has the prescription for modafinil (Provigil) filled. 3. Have the client purchase sodium oxybate (Xyrem) over the counter to prevent daytime drowsiness. 4. Be certain the client obtains antihistamines to control nasal stuffiness.

2

The nurse is notified about new state practice act regulations. Which type of law should the nurse expect to implement and enforce the nurse practice act regulations? 1. Statutory law 2. Administrative law 3. Common law 4. Public law

2

The nurse is performing urinary catheterization for a client. After using the nondominant hand to separate the client's labia for cleansing, the nurse will maintain this hand as being 1. sterile. 2. contaminated. 3. able to evaluate the effectiveness of the catheter balloon. 4. clean.

2

The nurse should incorporate which instructions into the teaching plan for a client with a urinary diversion? 1. Change the appliance several times a day. 2. Increase fluid intake. 3. Notify the physician if the stoma is deep pink and shiny. 4. Strands of blood may appear in the urine.

2

The parent of a preschool-age child asks the nurse what can be done to reduce the number of nightmares the child experiences. What should the nurse suggest to this parent? 1. Provide hot chocolate prior to bedtime. 2. Limit or eliminate television. 3. Engage in a physical activity before bedtime. 4. Play a computer game before bedtime.

2

Which nursing diagnosis would be appropriate for a client who has a retention catheter if the drainage bag is found lying on the floor? 1. Risk for Impaired Skin Integrity related to catheter placement 2. Risk for Infection related to improper handling 3. Self-Care Deficit related to presence of a retention catheter 4. Risk for Incontinence related to an obstruction

2

The nurse is working on a hospital committee tasked with reducing environmental distractions to sleep within the hospital. Which recommendations by the committee would be helpful? Standard Text: Select all that apply. 1. Turn off all overhead lights on the unit and use night-lights and flashlights. 2. Establish a time at which radios and televisions should be turned off or down. 3. Discontinue use of the paging system after 2100. 4. Conduct nursing reports in the hallway. 5. Open curtains between beds in semiprivate rooms.

2,3

The nurse manager determines that a staff nurse demonstrates understanding of the professional responsibility to advocate for a client's health, safety, and rights. What did the manager observe to come to this conclusion about the staff nurse? Standard Text: Select all that apply. 1. Reporting a medication error that he was responsible for making 2. Notifying the unit manager that a nurse is showing signs of being under the influence of alcohol 3. Being sure the computer screen is not visible to visitors when charting 4. Asking the client to explain in her own words the purpose of the research project she asked to act in as a participant 5. Calling the health care provider to clarify a confusing prescription for a client's pain

2,3,4,5

The nurse is teaching a client on the use of a cane. What should the nurse include in this teaching? Standard Text: Select all that apply. 1. Hold the cane on the weaker side of the body. 2. Move the cane forward while the body weight is between both legs. 3. The length of the cane should permit the elbow to be fully extended. 4. Move the weaker leg forward while the weight is between the cane and the stronger leg. 5. Move the stronger leg forward while the weight is between the cane and the weaker leg.

2,4,5

A client with lung disease is strongly urged to stop smoking but likes to smoke and does not know what to do. In what order should the nurse take the following actions to help this client clarify values? Standard Text: PUT IN ORDER 1. Choose freely. 2. List alternatives. 3. Affirm the choice. 4. Act with a pattern. 5. Examine consequences of choices. 6. Examine feelings about the choice.

2,5,1,6,3,4

A 5-year-old client has recurrent night terrors. What nursing intervention should the nurse use to help alleviate this problem? 1. Have the child walk around in the room when night terrors occur. 2. The next morning, ask the child to describe the event. 3. Have the child empty the bladder prior to going to bed. 4. Use an additional pillow behind the child's head at night.

3

A client is diagnosed with an elevated aldosterone level. The nurse realizes that this finding will affect what aspect of urinary elimination? 1. Increased urine output 2. Urinary incontinence 3. Decreased urine output 4. Urinary retention

3

A client is suing the hospital for malpractice. Before the case goes to court, the attorney meets with staff and reads the medical record. The nurse realizes that the attorney is performing which activity? 1. Burden of proof 2. Complaint 3. Discovery 4. Civil action

3

A client who has been blinded as result of an injury informs the rehabilitation staff of planning to return to her counseling practice and working full-time. The nurse should realize that this client is demonstrating which aspect of values clarification? 1. Choosing 2. Prizing 3. Acting 4. Clarifying

3

A client with terminal cancer is refusing food and fluids, and pushes the caregiver's hands away when attempts are made to feed the client or offer any kind of fluid. The family is considering placing a gastrostomy tube because they feel the client is "starving to death." What should the nurse do? 1. Honor the family's wishes and have them sign a consent form. 2. Talk to the physician so he or she can move forward with the family's wishes. 3. Honor the client's refusal and help the family come to terms with the situation. 4. Take the case to the hospital's ethics committee.

3

A client's urinalysis is reported as being normal. What were the client's results? 1. Blood present and no ketones 2. Dark amber color and output less than 500 cc in 24 hours 3. pH 6 and no glucose present 4. Specific gravity 1.035 and faint aromatic odor

3

A hospital receives notice of being sued for an action performed by a nurse. The nurse realizes that which doctrine is being implemented in this case? 1. Contractual relationship 2. Stare decisis 3. Respondeat superior 4. Res ipsa loquitur

3

A hospitalized client is being woken up every hour during the night for care and procedures. The nurse realizes that the lack of NREM sleep can have which physiological effect? 1. Decrease urine output 2. Increase thirst 3. Increase susceptibility to infection 4. Decrease heart rate

3

A nurse is working with a local agency to provide care to the inadequately insured by helping to staff an after-hours clinic. Which professional value is the nurse demonstrating? 1. Human dignity 2. Altruism 3. Social justice 4. Integrity

3

A student is attending a school with a high first-time pass rate on the NCLEX®. Which student statement articulates a belief that the nursing student has about faculty in the program? 1. Expect high academic standards from their students 2. Are concerned with job placement of their graduates 3. Are most concerned with the successful licensure of each student 4. Work hard to make sure students are successful

3

Before applying for re-licensure, the nurse attends continuing education programs. Which action is the nurse performing to adhere to the state board of nursing expectation? 1. Licensure 2. Competency 3. Credentialing 4. Certification

3

During a prenatal visit, the nurse is instructing a newly pregnant client in regard to exercise. What advice is best for the nurse to give this client? 1. Pregnant clients can exercise if exercise was a part of their life prior to pregnancy. 2. Due to the stress of a growing fetus, exercise should be limited to no more than 10 minutes per day. 3. Healthy pregnant women should exercise at least 30 minutes on most if not all days. 4. The pregnant woman's exercise should actually increase above normal recommended levels to prevent water weight gain.

3

The 70-year-old client tells the nurse, "I can go to sleep without a problem, but then I wake up in a couple of hours and can't go back to sleep." What nursing action would help promote rest and sleep in this client? 1. Have the client develop a bedtime ritual of quiet music and a glass of wine. 2. Encourage the client to avoid taking pain medication prior to sleep. 3. Evaluate if the client perceives sleeplessness to be a serious problem. 4. Have the client perform moderate exercises before bedtime.

3

The administration of a hospital, along with nursing services, is planning to incorporate a struggling private clinic into the infrastructure of the hospital. Although relocating the clinic may cause transportation difficulty for some clients, keeping the clinic running will allow current employees as well as clients the continued benefit of the clinic. Which moral framework did the hospital leadership use to make this decision? 1. Teleological theory 2. Deontological theory 3. Utilitarianism 4. Caring theory

3

The bed-bound client complains of pain and burning in the right calf area. What action should be taken by the nurse? 1. Deeply palpate the area for rebound tenderness. 2. Percuss over the area for change in tone. 3. Measure the calf and compare to the opposite calf. 4. Medicate the client for pain and reassess in 30 minutes

3

The client has complained of stiffness and muscle tension in his back. The nurse suggests a back rub, but the client declines the offer. What action should the nurse take? 1. Encourage the client to accept the back rub, saying how much it will relax the back muscles. 2. Document that the client is noncompliant with the nursing plan of care. 3. Accept the declination but tell the client to call if he changes his mind. 4. Instruct the UAP to rub the client's back while assisting him to change into a clean gown.

3

The client presents her hand when the nurse makes this statement: "I need to start an IV so you can get your antibiotics." Which behavior did the client demonstrate? 1. Informed consent 2. Express consent 3. Implied consent 4. Compliance

3

The client reports difficulty sleeping. Which environmental intervention should the nurse recommend? 1. Play soft music throughout the night. 2. Keep a television on in the bedroom. 3. Provide white noise with a fan. 4. Play a talk radio station.

3

The client who has obstructive sleep apnea is being treated with a nasal continuous positive airway pressure (CPAP) device, but has just been prescribed modafinil (Provigil). What client statement indicates that teaching about these therapies has been effective? 1. "I am so glad that I won't have to sleep in this machine anymore." 2. "Once I get regulated on the Provigil, I will wean myself off the CPAP." 3. "I will continue using my CPAP machine at night." 4. "I can turn down the pressure on my CPAP machine in about 1 week."

3

The client's chief complaint is, "I just can't get around like I used to. I have to stop halfway up the stairs to the bedroom, and just walking to the bathroom makes me so tired." Which nursing diagnosis is most likely appropriate for this client? Activity Intolerance: 1. Level 1. 2. Level 2. 3. Level 3. 4. Level 4.

3

The hospitalized client requests a bedtime snack. Which food should the nurse offer this client? 1. Hot chocolate 2. Tea and crackers 3. Cereal with milk 4. Chips and salsa

3

The newly admitted client has contractures of both lower extremities. What nursing intervention should be included in this client's plan of care? 1. Frequent position changes to reverse the contractures 2. Exercises to strengthen flexor muscles 3. Range-of-motion exercises to prevent worsening of contractures 4. Weight-bearing activities to stimulate joint relaxation

3

The nurse forgets to put the call light within the client's reach and then leaves the room. The client reaches for it and falls out of bed. With what should the nurse expect to be charged? 1. Assault 2. Battery 3. Negligence 4. Criminal intent

3

The nurse is assisting the client to dangle on the bedside. After raising the head of the bed, in which position should the nurse face? 1. Toward the nearest corner of the head of the bed 2. Toward the side of the bed 3. Toward the far corner of the foot of the bed 4. Directly toward the client

3

The nurse is concerned that an older client with a retention catheter is developing a urinary tract infection. What assessment finding caused this concern? 1. Elevated blood pressure 2. Elevated heart rate 3. Confusion 4. Leg pain

3

The nurse is identifying outcomes for a client with the nursing diagnosis Stress Urinary Incontinence. Which outcome would be related to sphincter incompetence? 1. The client will empty her bladder every time she voids. 2. The client will improve her incontinence within 1 month. 3. The client will perform four to five squeezes for 5 to 10 seconds. 4. The client will stop the flow of urine when voiding.

3

The nurse is providing range-of-motion exercising to the client's elbow when the client complains of pain. What action should the nurse take? 1. Stop immediately and report the pain to the client's physician. 2. Discontinue the treatment and document the results in the medical record. 3. Reduce the movement of the joint just until the point of slight resistance. 4. Continue to exercise the joint as before to loosen the stiffness.

3

The nurse is working with a client to develop an expected outcome for the nursing diagnosis Disturbed Sleep Pattern, difficulty staying asleep related to anxiety secondary to multiple life stressors. Which expected outcome would be most applicable to this client's situation? 1. The client will sleep at least 8 hours each night. 2. The client will list three positive coping mechanisms for anxiety relief. 3. The client will report getting sufficient sleep to provide energy for daily activities. 4. The client will manifest less anxiety after taking prescribed medications.

3

The nurse realizes that which client is at risk for difficulty in urinary elimination? 1. A client who had bladder cancer and now has a newly created ileal conduit 2. A 25-year-old female client with low self-esteem 3. An 80-year-old male reporting frequent urination at night 4. The client with hypertension who takes a diuretic every day for blood pressure

3

The postoperative client is ambulating for the first time since surgery. The client has been able to tolerate sitting up on the side of the bed and has stood at the bedside without difficulty on two occasions. Which staff member should ambulate this client? 1. The UAP 2. A licensed practical (vocational) nurse 3. A registered nurse 4. It makes no difference

3

What is the priority action of the nurse prior to transferring a client from bed to wheelchair? 1. Place the bed in its lowest position. 2. Place the wheelchair parallel to the bed. 3. Lock the brakes on the bed. 4. Place a transfer belt on the client.

3

Which intervention would the nurse plan to help a client prevent a urinary tract infection? 1. Encourage the use of bubble baths. 2. Have the client increase sugar in the diet. 3. Instruct the client to empty the bladder completely. 4. Wipe from back to front.

3

While assisting the client with a bath, the nurse encourages full range of motion in all the client's joints. Which activity would best support range of motion in the hand and arm? 1. Give the client a washcloth to wash the face. 2. Move the wash basin farther toward the foot of the bed so the client must reach for it. 3. Have the client brush the hair and teeth. 4. Move each of the client's hand and arm joints through passive range of motion.

3

A client needs a test to determine the amount of residual urine. The nurse realizes that this assessment is used for which reason(s)? Standard Text: Select all that apply. 1. To evaluate the glomerular filtration rate 2. To determine the extent of renal failure 3. To determine the amount of retained urine after voiding 4. To determine the need for medications 5. To evaluate fluid volume status

3,4

The nurse is assisting in logrolling a client recovering from spinal surgery. Why should the nurse place a pillow between the client's legs when turning? Standard Text: Select all that apply. 1. Stabilizes the spine 2. Prevents hip contractures 3. Supports the upper leg 4. Keeps the legs parallel and aligned 5. Prevents adduction of the upper leg

3,4,5

A client being prepared for an invasive procedure questions some of the terminology in the consent form. Which response should the nurse make? 1. "Just sign the form, and I'll make sure your physician talks to you before he begins the procedure." 2. "I'll explain whatever you don't understand." 3. "You should have asked your physician when he was in here." 4. "I'll call your physician back in the room to answer your questions."

4

A client is instructed on the care of an indwelling urinary catheter. Which returned demonstration by the client indicates that teaching has been effective? 1. The client empties the drainage bag once a day. 2. The client hangs the drainage bag on the towel rod. 3. The client refuses drinks one to two 8-ounce glasses of fluid each day. 4. The client takes a shower each day.

4

A client is working two jobs, caring for aged parents, and maintaining a household for the family. The nurse realizes that this emotional stress will have what impact on the client's sleep? 1. More REM sleep 2. Less Stage 1 and Stage II NREM sleep 3. More NREM sleep 4. Less deep sleep and more awakenings during the night

4

A client was given the wrong dose of medication and died. The case is being tried in court and similar cases are used by the court in comparison to arrive at a decision. Which doctrine should the nurse's attorney explain is applied to this situation? 1. Common law 2. Public law 3. Administrative law 4. Stare decisis

4

A client with a sexually transmitted illness (STI) asks the nurse to not tell anyone about the diagnosis. According to the Health Insurance Portability and Accountability Act (HIPAA) of 1996, what must the nurse do? 1. Honor the client's wishes. 2. Not disclose any information to anyone. 3. Respect the client's privacy and confidentiality. 4. Communicate only necessary information.

4

A client's results from a urinalysis are as follows: pH 5.2, gross cloudiness, WBC 10-15, glucose negative, specific gravity 1.012, and protein negative. How should the nurse interpret the results? 1. Dehydration 2. Diabetic ketoacidosis 3. Trauma 4. Urinary tract infection

4

A decision has been made for an older client to receive aggressive cancer therapy despite knowing that the therapy will actually be more harmful than the disease and subject the client to harmful chemicals. With which ethical principle is this nurse caring for this client struggling? 1. Autonomy 2. Justice 3. Beneficence 4. Nonmaleficence

4

A nurse manager has a staff nurse who observes certain religious holidays. The manager tries to make sure that these observances can be met if possible. Which value is the manager practicing? 1. Human dignity 2. Social justice 3. Autonomy 4. Altruism

4

A student nurse accidentally left the call light outside the reach of an older client. Another nurse discovered the situation and was able to rectify the matter before something happened. The student apologizes and states the need to double check for call light placement before leaving a client's room. What behavior did the student demonstrate? 1. Justice 2. Fidelity 3. Responsibility 4. Accountability

4

The RN is admitting a client to the medical unit for a urinary disorder. Which physical assessment techniques should the nurse use in assessing this client's urinary system? 1. Auscultation and inspection 2. Inspection and percussion 3. Observation and auscultation 4. Palpation and observation

4

The client is being treated with a nasal continuous positive airway pressure device (CPAP) for sleep apnea. What finding indicates that this treatment has been helpful to the client? 1. The client has lost 7 pounds since treatment began. 2. The client sleeps so soundly that he snores. 3. The client's diabetes is now under control. 4. The client reports a decrease in morning headache.

4

The client who has sleep apnea reports falling asleep while driving, almost being involved in an accident, and frequent episodes of sleepwalking. What nursing diagnosis should be a priority for this client? 1. Disturbed Sleep Pattern related to difficulty staying asleep 2. Risk for Impaired Gas Exchange related to sleep apnea 3. Disturbed Thought Processes related to chronic insomnia 4. Risk for Injury related to somnambulism

4

The nurse carries out a medication order, incorrectly written by the physician and subsequently filled by the pharmacist. Who, in this situation, is legally liable for the action? 1. Physician 2. Pharmacist 3. Hospital 4. Nurse

4

The nurse is applying an external urinary device to a client. Before attaching the device to the drainage bag, what should the nurse do? 1. Wash his or her hands. 2. Document the client's tolerance of the procedure. 3. Instruct the client about the drainage system. 4. Ensure that the condom is not twisted.

4

The nurse is determining tasks to delegate to unlicensed assistive personnel (UAP). Which task should the nurse question before delegating to this level of health care provider? 1. Measuring intake and output 2. Assessing vital signs for clients who are clinically stable 3. Performing complete morning care for a client recovering from a stroke 4. Inserting a urinary catheter into a client

4

The nurse is working on a hospital committee focused on preventing back injury in nurses. Which recommendation by this committee is most likely to result in a decrease in back injuries if followed? 1. Nurses must wear back belts when lifting clients. 2. All nursing personnel must attend annual body mechanics education. 3. In order to prevent injury, nurses must strive to become physically fit. 4. No solo lifting of clients is permitted in the facility.

4

The nurse must lift a 15-pound box of supplies from a low shelf on the supply cart to a table. Which technique should the nurse use to protect the back? 1. Place the feet together to provide a strong base of support. 2. Flex the knees to lower the center of gravity. 3. Face the box, pick it up, and rotate the upper body toward the table. 4. Hold the box as close to the body as possible.

4

The nurse, seeing a client asleep, turns off the television in the room. The client opens her eyes and says "I was watching that. I wasn't sleeping." The nurse realizes that the client was demonstrating which stage of NREM sleep? 1. IV 2. III 3. II 4. I

4

Which nursing intervention is appropriate when caring for a client with a retention catheter? 1. Don sterile gloves. 2. Gently retract the labia majora away from the urinary meatus. 3. Observe urine in the drainage bag. 4. Retape the catheter to the thigh.

4

A UAP has applied a condom catheter to a client. The nurse should document what information about this procedure? Standard Text: Select all that apply. 1. Number of ml of fluid used to inflate the balloon 2. Location of the drainage bag 3. Name of the UAP who applied the device 4. Time and date that the condom catheter was applied 5. Integrity of the penis

4,5

The nurse is assessing a client in the intensive care unit who is asleep. What physiological changes will the nurse observe in this client? Standard Text: Select all that apply. 1. Lower respiratory rate 2. Increased muscle tension 3. Increased lower extremity edema 4. Lower blood pressure 5. Lower heart rate

4,5

The nurse is reviewing the ANA (American Nurses Association) Code of Ethics for Nurses. What should the nurse identify as a characteristic of this code? 1. It is a formal statement. 2. It contains the same standards as legal standards. 3. It is shared by group members. 4. It reflects legal judgments. 5. It serves as a standard for professional actions.

5

A client with an indwelling urinary catheter is prescribed to receive sterile normal saline bladder irrigation at 100 mL/hr. After an 8-hour shift the nurse measures the client's output as being 1425 mL. What is the client's urine output for the 8-hour shift? Standard Text: Calculate to the nearest whole number.

625ML

The nurse is reviewing kidney function with a client experiencing renal failure. Identify the area in the nephron where solutes such as glucose are reabsorbed.

LOOP OF HENLE