EAQ 4

Which nursing diagnosis is best to formulate for a 76-year-old client who is exhibiting an external locus of control?

B

The nurse instills an atropine ophthalmic solution into both eyes for a client who is having a routine eye examination. Which side effects should the nurse tell the client to anticipate?

Blurred vision

A nurse gives a client a narcotic for pain and must now leave the unit. To whom should the nurse delegate the task of evaluating the client's response to the pain medication?

C

After attending an inservice for bioterrorism preparedness and staff education, the nurse should identify which findings consistent with a possible anthrax exposure?

C

At what phase of the therapeutic relationship should the nurse ask a male client about his reasons for seeking medical care and hospitalization?

C

During a mass casualty incident involving a 1000 or more victims, which action is the priority for the nurse to implement?

C

The nurse identifies the nursing diagnosis of, Visual sensory/perceptual alterations related to increased intraocular pressure (IOP) for a client with glaucoma. Which nursing intervention should the nurse include in the plan of care?

C

The nurse is teaching a client with Addison's disease about this new diagnosis. What pathophysiological explanation should the nurse share with the client?

C

Which change in sleep patterns is most likely to occur in an older adult?

C

Which client information should the nurse obtain that is indicative of the presence of cholelithiasis?

C

Which evidence supports the application of healthcare informatics and client care technology?

C

Which family-centered care concept(s) should the nurse encourage family members to use to promote child growth, development, and independence?

C

The nurse is catheterizing a 7-year-old boy who has been admitted to the pediatric unit. After cleansing the glans penis, what should the nurse do first to minimize discomfort?

Insert 5 ml of 2% lidocaine lubricant into the urethra.

An older Chinese client refuses to perform the range-of-motion and breathing exercises after a surgical procedure and is hesitant to complete hygienic care and grooming. What cultural factor should the nurse consider that is related to this client's behavior?

D

An older client who is admitted with terminal cancer of the liver begins to talk with the nurse about spiritual life after death. Which response by the nurse best assesses the client's spiritual needs?

D

The charge nurse assigns one nurse to care for a client with shingles and another nurse to care for a client with HIV/AIDS. Which client goal is addressed by the charge nurse's assignments?

D

A client is prescribed a STAT dose of IV insulin. Which vial should the nurse select to prepare the dose?

Insulin regular (Humulin R).

The nurse is planning care for a child with Trisomy 21 who is admitted with recurrent upper respiratory infections and chronic constipation. Which intervention should the nurse include in the plan of care?

Use a bedside cool-mist vaporizer during naps and night time.

The nurse is instructing a mother about the care of her child who has pediculosis capitis. Which information should the nurse provide?

Use a fine-toothed comb or tweezers to remove nits.

A male client with gastric cancer is 1 week postoperative for a total gastrectomy and has normal hematologic parameters. Which vitamin should the nurse explain to the client is indicated to take for his lifetime?

Vitamin B12

The parents of a 4-month-old infant who is hospitalized tell the nurse that they have to work and cannot stay with the baby except on weekends. Which actions should the nurse-manager implement to address the infant's emotional needs?

Assign the same nurse to care for the child each day.

A client who begins an exercise program asks the nurse about carbohydrate loading. What concepts should the nurse include in teaching the client ways to increase glycogen store in muscles?

B

A male client has a prescription for disulfiram (Antabuse). Which adverse reaction should the nurse caution the client about while taking the medication?

B

A male client tells the nurse that he is frequently constipated. Which finding should the nurse identify as a common dietary cause of constipation?

B

During admission to the mental health unit, a female client with bipolar disorder, manic phase, is loud, hyperverbal, hyperactive, and is garishly dressed. Which intervention should the nurse include when planning care for this client?

Maintain an environment that reduces stimulation of the client.

When conducting an assessment interview with a new client, which question should the nurse use to elicit the most information?

Tell me about you family

An 11-year-old boy with oppositional defiant disorder becomes angry and defiant over the rules of the day treatment mental health program. Which response by the nurse is the most effective way to defuse the situation?

Tell the child to go to the gym to play basketball (redirect)

An adolescent female who lost fifty pounds during the past three months is hospitalized. During the admission assessment, the client complains of dry skin, poor skin turgor, hair breakage, brittle nails, and a history of menstrual cycle problems. Which finding is most important for the nurse to obtain additional assessment information?

Amenorhea (anorexia nervosa)

The mother of an 8-year-old child with a chronic illness and tracheotomy is rooming-in during this hospitalization. The mother insists on providing all of the child's care and tells the nurse how to care for the child. The nurse should recognize that the mother plays which function when planning this child's care?

An expert in care of the child.

An infant who is delivered at 32-weeks gestation arrives in the nursery intubated. After the infant is placed under a radiant warmer with prescribed ventilator settings, the nurse applies a cardiorespiratory monitor and pulse oximeter, which indicates an oxygen saturation of 80%. What action should the nurse implement first?

Ensure patency of the endotracheal tube.

During a group therapy session, a client with hypomania threatens to strike another client. What intervention is best for the nurse to implement?

Firmly inform the client that acting out in anger is not acceptable

The nurse is teaching an obese adolescent about lifestyle choices and ways to improve diet. Which interventions should the nurse include in the teaching plan?

Incorporate favorite foods into the adolescent's diet.

Which infant is at risk for Rh incompatibility?

Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor.

The nurse is conducting a retrospective chart audit to investigate whether outcomes recorded in each nursing care plan are client-centered and written in behavioral terms. The Continuous Quality Improvement (CQI) Committee's expected benchmark is 98% compliance. The sample size is 200 charts, and the results show 180 charts met the benchmark. Which evaluation outcome should the nurse conclude?

B

A client is comatose upon arrival to the emergency department after falling from a roof. The client flexes with painful stimuli, and the nurse determines the client's Glasgow Coma Scale (GCS) is 6. Which intervention should the nurse prepare to implement to maintain the client's airway?

>>A nasopharyngeal tube. If head and neck injuries are suspected, a client with a GCS of 6 who demonstrates motor flexion in response to painful stimuli requires airway maintenance without risk of compromise to spinal cord function. Nasal intubation using a nasopharyngeal tube (C) is the airway of choice for a client with suspected spinal cord injury because less cervical spine manipulation is needed during insertion, as compared with endotracheal intubation

A male client who is admitted with a bleeding peptic ulcer develops sudden, severe upper abdominal pain. The client becomes diaphoretic and draws his knees over his abdomen. Which finding should the nurse report to the healthcare provider?

>>A rigid, boardlike abdomen (Peritonitis caused by leakage of gastric secretions and blood into abdominal cavity)

The nurse is developing the plan of care for an older client who is immobile and at risk for pressure ulcers. Which contributing factor should the nurse include in the nursing diagnosis, "Risk for altered skin integrity?

B

A primiparous client has been in labor for 15 hours. Two hours ago, vaginal examination revealed the cervix dilated to 5 cm, 100% effaced, and the presenting part at station 0. Five minutes ago, the vaginal examination reveals no change in the cervix or decent of the fetus. Which labor pattern should the nurse document to describe the client's progress?

>>Arrest of active phase. Arrest of active phase (B) is indicated if there is no change in the dilation of the cervix for 2 hours or more in a primigravida. Prolonged latent phase (C) is labor lasting longer than 20 hours in a primigravida. Protracted active phase (D) occurs when dilatation of the cervix is less than 1.2 cm/hour. Protracted descent (A) occurs when the fetus decends less than 1 cm/hour into the pelvis.

A client with gastroesophageal reflux disease (GERD) is unconscious and unresponsive to stimuli. The nurse places the client in a side-lying position. The nurse should monitor the client for the risk of which complication?

>>Aspiration Pneumonia

The nurse reviews a client's laboratory results and identifies an elevated serum ammonia level. Which pathophysiological process contributes to this finding?

>>Failure of the liver to convert ammonia absorbed from the bowel to urea. As a result of hepatocellular damage, the pathogenesis of hyperammonemia occurs when the liver fails to convert ammonia absorbed from the bowel to form urea (C) for eventual excretion by the kidneys.

A client returns to the unit after abdominal Nissen fundoplication for treatment of gastroesophageal reflux disease. After 4 hours, the nurse determines the client has no drainage from the nasogastric tube (NGT) and has absent bowel sounds. What action should the nurse implement?

>>Irrigate the NGT with NS (After abdominal surgery, patency of the NGT should be maintained to avoid the need to reinsert the tube, which could possibility perforate the surgical repair site, so irrigation of the NGT (D) should be implemented to promote gastric drainage and decompression)

Which fetal heart rate (FHR) finding should the nurse report to the healthcare provider immediately?

>>Late decelerations Late decelerations (A) are caused by uteroplacental insufficiency and result in fetal hypoxemia, an ominous sign if persistent and should be reported to the healthcare provider immediately. Early decelerations in the FHR (B) are associated with head compression as the fetus descends into the maternal pelvic outlet and are common during normal labor. FHR accelerations with fetal movement (C) are an indication of fetal well-being. An average FHR of 126 beats per minute (D) is within normal limits.

A client returns from surgery after undergoing an abdominal-perineal resection with a sigmoid colostomy. The colostomy is dressed with petroleum jelly gauze and dry gauze dressings. The perineal incision is partially closed with two drains attached to Jackson-Pratt suction bulbs. During the early postoperative period, the nurse should give the highest priority to which nursing action?

>>Maintain dry perineal dressings During the immediate postoperative period, the perineal dressing should be assessed, reinforced, and changed frequently because profuse drainage during the first hours after surgery)

A client returns to the postoperative unit after a gastroduodenostomy (Billroth I) for treatment of a perforated ulcer. The healthcare provider's prescriptions include morphine with a patient-controlled analgesia (PCA), nasogastric tube (NGT) to low intermittent nasogastric suction, and IV fluids and antibiotics. The client complains of increasing abdominal pain 12 hours after returning to the surgical unit. The nurse determines the client has no bowel sounds, and 200 ml of bright red nasogastric drainage is in the suction canister in the past hour. What is the priority action the nurse should implement?

>>Notify HCP Although nasogastric aspirate can be bright red initially, the color should gradually darken over the first 24 hours. A sudden increase in the volume of bright red gastric drainage indicates bleeding, and the healthcare provider should be notified immediately

A client with an open reduction and application of an external fixator for open, comminuted fractures of the tibia and fibula begins to complain of severe pain in the affected leg, which is not relieved by analgesics. The client says the toes are numb and tingling, although they appear pink. What action should the nurse implement?

>>Notify HCP Early recognition and treatment of compartment syndrome is critical, so the healthcare provider should be notified as soon as an elevated intra-compartmental pressure is suspected (A). The client's core body temperature )

On the second day after admission, a client with a fractured pelvis develops chest pain, tachypnea, and tachycardia. Which additional finding should the nurse identify that is most likely related to a fat embolism?

>>Petechiae of the anterior chest wall. (The pathophysiologic process of fat embolism syndrome (FES) after fracture is related to the release of bone marrow fat globules into the venous circulation followed with platelet aggregation. Fat emboli lodge in the pulmonary vasculature, result in tissue hypoxia, and manifest as petechiae on the neck, anterior chest wall (D), axilla, buccal membrane, and conjunctiva of the eye. )

The nurse is assessing a postpartum client who delivered in the car. Which finding should the nurse identify as the earliest manifestation of a puerperal infection?

>>Temperature of 100.8° F 24 hours after delivery. Postpartum or puerperal infection is any clinical infection of the genital canal that occurs within 28 days after miscarriage, induced abortion, or childbirth. The presence of a fever of 38° C (100.4° F) 24 hours after birth is the first indicator (

The nurse is evaluating the external fetal monitor and identifies variable fetal heart rate (FHR) decelerations. The nurse recognizes that this change in the FHR pattern is due to which pathophysiological incident?

>>Umbilical cord compression Variable decelerations occur any time during the uterine contracting phase and are caused by compression of the umbilical cord (B) between the fetus and maternal pelvis, the fetal cord around the fetal neck, arm, leg, or other body part, a short cord, a knot in the cord, or a prolapsed cord.

In reviewing the medical record, the nurse notes that a client's last eye examination revealed an intraocular pressure (IOP) of 28 mmHg. What information should the nurse ask the client?

>>Use of prescribed eye drops since last exam by ophthalmologist Normal intraocular pressures range between 10 and 21 mmHg, so the client's use of any prescribed eye drops should be determined to evaluate the client's intraocular pressure)

The nurse is evaluating a client's response to diuretic therapy. Which assessment provides the best measure of the client's fluid volume status?

B

A client who is a laboratory technician and has a history of allergic rhinitis, asthma, and multiple food allergies is scheduled for surgery. Which action should the nurse implement?

>>doc't possible type I latex allergy Risk factors for latex allergy include long-term multiple exposures, such as healthcare personnel, multiple surgeries, and a client history of allergies, such as hay fever, asthma, and foods. Documentation of the client's risk for a Type I latex allergy (A) should be noted in the client's medical record. )

Which information is most important for the nurse to provide parents about long-term care for their child with hydrocephalus and a ventriculoperitoneal (VP) shunt?

>Shunt malfunction or infection requires immediate treatment.

The healthcare provider prescribes digital evacuation of a fecal impaction for an older client who is admitted with a closed head injury after falling out of bed. As a part of the procedure policy, the nurse applies a topical anesthetic gel to the rectum. Which rationale best supports the use of the anesthetic gel?

A

The nurse is administering a nasogastric tube feeding to a client who is comatose. Which finding requires further action by the nurse?

A

The nurse is caring for a client who is one-day post cardiac catheterization with stent placement. Assessment findings are: blood pressure 90/40, heart rate 45 beats/minute, and oxygen saturation at 95% on oxygen nasal cannula at 2 L/minute. Which task should the nurse delegate to the unlicensed assistive personnel (UAP) at this time?

A

The nurse is obtaining a client's consent for a paracentesis. Which information should the nurse provide to ensure the client understands the purpose of the procedure?

A

The nurse manager is explaining to a new nurse that the nursing units at the hospital are managed by the nursing staff who control self-scheduling of shift work, implement unit quality improvement program, and participate in unit recruitment-retention programs. What type of management model is the nurse manager describing?

A

What description encompasses the role in client care management played by nursing informatics?

A

What nursing intervention should the nurse include in the plan of care for a client following a bone marrow aspiration?

A

A male client calls the crisis center and tells the nurse that he wants to die and is planning to commit suicide. What means of suicide should the nurse determine is most lethal if in the client's possession?

A loaded gun

The nurse is providing comfort and palliative care for a terminally ill client who is experiencing nausea and vomiting. Which action is best for the nurse to take to promote the client's comfort?

B

What assessment finding should the nurse identify in a client with fluid volume excess?

B

What is the largest contributing factor for the increase in the need for home care?

B

Which action should the hospice nurse implement to assist a client maintain self-worth during the end-of-life process?

B

Which individual may legally sign an informed consent?

B

Which intervention demonstrates the nurse's accountability in a specific decision-making process?

B

A 38-year-old female client is admitted to the mental health unit after a recent manic episode of spending large amounts of money on new furniture, making excessive long-distance phone calls, and not sleeping for three days. During the admission process, the client is wearing a green bathing suit. What intervention should the nurse implement?

Assess the client's needs for food, liquids, and rest.

A client with advanced cirrhosis and hepatic encephalopathy is manifesting mounting ascites and 4+ pitting edema of the feet and legs. The nurse identifies fluid leaking from his skin when he is turned. Which intervention is most important for the nurse to include in the client's plan of care?

Apply a pressure-relieving mattress under the client.

Three days after a colon resection, the nurse is assessing a client with a nasogastric tube (NGT) to intermittent suction. What assessment should the nurse implement to determine proper placement of the NGT?

Aspirate the tube contents to test the pH.

Which intervention(s) should the nurse use when interacting with a client with Alzheimer's disease? (Select all that apply).

C,E

The nurse is reviewing the laboratory results of an older client who is admitted to a medical unit. Which serum chemistry values should the nurse recognize as most commonly affected by the aging process? (Select all that apply.)

Ca, K, Na

A 32-year-old male client is admitted with paranoid schizophrenia. The nurse observes the client walking around the unit muttering to himself and gesturing as if he is having auditory hallucinations. Which action provides the most effective psychotherapeutic management?

D

A client with chronic kidney disease (CKD) receives peritoneal dialysis at home and is upset because of the expenses of therapy. What information response should the home health nurse provide as the client's advocate?

D

A male client gives a copy of his living will to the nurse upon admission to the hospital. What action should the nurse implement if the client is unable to express his desire about life-prolonging measures?

D

A mother asks the nurse to explain how using time-out to discipline her 2-year-old child is an effective method. Which rationale should the nurse provide?

D

An adolescent client is admitted to the mental health unit for impulsivity and acting-out behavior at school. What intervention should the nurse implement that is most beneficial for this client?

D

The nurse is assessing a child of Chinese descent who arrives in the clinic with an upper respiratory infection and identifies a 5-inch, circular ecchymoses on the child's forehead and back. What factor should the nurse consider as the most likely cause of this finding?

D

The nurse is caring for a client who is scheduled for surgery in 2 hours. The client tells the nurse, "My doctor came by to tell me a lot of stuff that I didn't understand, but I signed the papers for surgery anyway." To fulfill the role of advocate, which action should the nurse implement?

D

The nurse notes a client with decreased alertness is having difficulty managing saliva. What is the priority assessment for the nurse to implement prior to feeding?

D

What clinical problem is a suitable for research utilization in nursing?

D

Which components are characteristic of practice context?

D

Which entry in the client's medical record provides the best documentation of client care?

D

Which information is most accurate for the nurse to use when calculating safe drug dosages for a child?

D

Which intervention is most important for the nurse to include in the plan of care for a client with ankylosing spondylitis?

D

Which principle should the nurse use to delegate client care to an unlicensed assistive personnel (UAP)?

D

A female client who is diagnosed with an eating disorder has difficulty translating her pain into words. Which approach should the nurse implement to allow this client greater self-disclosure?

Dance therpay

client is using an otic solution, hydrocortisone and polymyxin B (Otobiotic otic), for external otitis media. Which therapeutic response should the nurse tell the client to expect?

Dec. inflammation and pain

The nurse is explaining dietary management to a client with pregestational diabetes during a prenatal visit. Which client statement indicates that the teaching has been effective?

Diet and insulin needs will change significantly throughout my pregnancy.

The nurse is supervising an unlicensed assistive personnel (UAP) who is feeding an older client with dysphagia. Which action by the UAP requires the nurse's intervention?

Divides solid food items into one inch cube pieces

The nurse is suctioning the tracheostomy for a child who is experiencing rhonchi and unable to expel mucus. Which action should the nurse implement to provide effective pulmonary toileting?

Each pass of the suction catheter should take no longer than five seconds.

To avoid a false positive result for fecal occult blood in a stool specimen, the nurse should instruct the client to avoid ingestion of which substances prior to collecting a sample? (Select all that apply.)

Fish Beef Ibuprofen (Advil)

In which order should the nurse implement these actions when withdrawing a solution from an ampule?

Flick the stem several times with a finger. Wrap the neck with a protective device. Break the neck by pressing thumbs outward. Stabilize ampule on a firm surface. Withdraw the solution using a filter needle.

A female client arrives at the clinic because her boyfriend received the results of a Gram stain smear that revealed the presence of Neisseria gonorrhoeae. The client tells the nurse that she has not had any symptoms and almost did not come to the clinic. What information should the nurse provide the client?

Gonorrhea is often asymptomatic in women because the infection is not visible. (often overlooked as yeast discharge or urinary infection)

What information in a client's history indicates the highest risk factor for Hepatitis C?

IV drug abuse

The nurse-manager is planning to study a unit problem that engages the nursing staff in evidence-based practice. What is the sequence of activities that the nurse-manager should use? (Arrange in the order from first on top to last on the bottom.)

Identification of practice problem. Review of published research. Implementation of data gathering methods and data evaluation. Identify and develop plan for application of research findings.

A mother brings her 4-year-old boy to the clinic because he spends his day in constant motion, talks excessively, and is easily distracted from playing with his toys. His preschool teacher is unable to keep him focused in the classroom and suggested he undergo a mental health evaluation. Which nursing diagnosis should the nurse formulate?

Impaired Social Interaction

Upon admission, the nurse determines a male client with alcohol withdrawal syndrome is experiencing visual and auditory hallucinations, confusion, dehydration, a swollen tongue, and bruising. Which action should the nurse include in this client's plan of care to ensure physiological stability?

Monitor VS

Which action should the nurse implement to assess for jugular vein distention (JVD) in a client with heart failure (HF)?

Observe the vertical distention of the veins as the client is gradually elevated to an upright position.

The nurse identifies a break in sterile technique as a client is draped for an operative procedure. What action should the nurse implement?

Point out the observation immediately to the surgical team.

The neonatologist requests a mother to provide breast milk for her 32-week gestational premature newborn. The nurse provides instructions about pumping, storing, and transporting the breast milk. Which additional information should the nurse include to ensure the mother understands the request?

Providing breast milk ensures the premature newborn can easily digest and absorb the nutrients.

Before administering timolol maleate (Timoptic) to a client with open-angled glaucoma, which finding should the nurse report to the healthcare provider?

Receives carvedilol (Coreg) for heart failure (HF). A client who is receiving a beta-blocker, such as carvedilol (Coreg), for HF or hypertension is at risk for additional systemic effects from ophthalmic beta blockers, such as Timoptic, so the healthcare provider should be notified of the client's current prescriptions

The nurse is instructing a client about the use of podofilox (Condylox) for the treatment of genital warts. Which information should the nurse provide?

Redness, peeling, and itching may occur at the site of application.

A client is receiving an opioid analgesic every 2 hours for intractable pain. Which pathophysiological consequence should the nurse identify if the client receives the medication at regular intervals?

Respiratory acidosis.

Pulse oximetry is being used to monitor a client's oxygen saturation. Which client risk factor(s) should the nurse consider as variable(s) that affect this measurement? (Select all that apply.)

Smoking Jaundice HoTN T1-DM

A mother brings her 4-week-old infant for the first well-child visit and tells the nurse that the baby is not smiling. Which information should the nurse provide?

Social smiling begins at approximately 2 months of age. Correct

A 50-year-old male client with amyotropic lateral sclerosis (ALS) is becoming increasingly debilitated and tells the nurse, Since I haven't been able to go to church, I feel out of touch with God. I pray, but I wonder whether my prayers are heard. Which nursing diagnosis should the nurse include in the client's plan of care?

Spiritual distress

Which therapeutic response should the nurse identify that best evaluates the use of reminiscence strategies with an older adult?

Stimulate memory through associations

When administering an intramuscular (IM) injection to an adult client using the ventrogluteal site, which landmarks should the nurse identify to locate the area for injection?

The anterosuperior iliac spine and the greater trochanter. Correct

The parents of a 5-year-old are concerned because their child showed more outward grief when a pet died than when a sibling died from sudden infant death syndrome (SIDS). What response should the nurse provide?

The child focuses on another connection because the sibling's death is misunderstood

A client who is taking nitroglycerin for angina is concerned about having headaches after taking more than one tablet. What information should the nurse provide?

This is a common side effect due to the vasodilatory effects of the medication.

The nurse is assessing a client who is receiving risperidone (Risperdal). The nurse should monitor the client for which common side effect that is most likely to occur during therapy?

Weight gain

The nurse is providing tracheostomy care for a client who has encrusted secretions inside the inner cannula. Which solution should the nurse use to remove the debris?

hydrogen peroxide