EAQs FUNDAMENTAL (Pg.6)TERM 2

A nurse assesses drainage on a surgical dressing and documents the findings. Which documentation is most informative?

"A 10-mm-diameter area of drainage at 1900 hours."

Which statement is true regarding democratic leadership?

"Democratic leadership emphasizes team building through joint efforts of all team members."

An adolescent that had an inguinal hernia repair is being prepared for discharge home. The nurse provides instructions about resumption of physical activities. Which statement by the adolescent indicates that the client understands the instructions?

"I can't perform any weightlifting for at least 3 weeks."

A complete blood count (CBC), urinalysis, and x-ray examination of the chest are prescribed for a client before surgery. The client asks why these tests are done. Which is the best reply by the nurse?

"They are done to identify other health risks."

A client asks the nurse, "Should I tell my partner that I just found out I'm HIV positive?" How should the nurse respond?

"You are having difficulty deciding what to say."

While receiving a preoperative enema, a client starts to cry and says, "I'm sorry you have to do this messy thing for me." What is the nurse's best response?

"You seem upset."

A client has a right above-the-knee amputation after trauma sustained in a work-related accident. Upon awakening from surgery, the client states, "What happened to me? I don't remember a thing." How should the nurse respond?

"You were in a work-related accident this morning."

A nurse teaches a client about wearing thigh-high anti-embolism elastic stockings. What would be appropriate to include in the instructions?

"You will need to apply them in the morning before you lower your legs from the bed to the floor."

A nursing student is learning about various health belief systems. Which characteristics describe the holistic health belief system? Select all that apply.

*Circumcision may be viewed as a religious practice *Healing powers may be ascribed to animate or inanimate objects. *Treatments are designed to restore balance with the physical, social, and metaphysical worlds.

A client with postural hypotension requires nursing care. Which task can be safely delegated by the registered nurse to unlicensed nursing personnel (UNP)? Select all that apply.

*Managing foot care of the client *Maintaining oral hygiene of the client

The nurse is caring for a client who underwent a hysterectomy and who is admitted to a general medical-surgical unit. Which tasks can be delegated to the unlicensed assistive personnel (UAP)? Select all that apply.

*Oral hygiene *Assistance with bathing

The Institute of Medicine (IOM) has identified five interrelated competencies that are essential for healthcare professionals in the 21st century. Which tasks performed by the nurse would satisfy the patient-centered care competency? Select all that apply.

*Relieving pain and suffering *Communicating with and educating clients effectively *Recognizing and respecting differences in clients' values, preferences, and needs

Which statement regarding delegation is true?

A licensed vocational nurse (LVN) is responsible for determining the degree of assistance that a client needs.

While assessing a client's vision, the nurse finds that the client is unable to read line 20 of the eye chart when made to stand at a distance of 20 feet. Which ophthalmic condition can be anticipated in this client?

Abnormal distant vision

After cataract surgery, a client reports feeling nauseated. How can the nurse help relieve the nausea?

Administer the prescribed antiemetic drug.

A nurse is caring for an older adult who is taking acetaminophen for the relief of chronic pain. Which substance is most important for the nurse to determine if the client is taking because it intensifies the most serious adverse effect of acetaminophen?

Alcohol

Elbow restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. What is most important for the nurse to do?

Assess the client's condition every hour

hich task is most appropriate for a nurse to delegate to unlicensed assistive personnel?

Assessing the blood pressure of a client before physical therapy.

Which addictive drug may cause stuffy nose, bronchitis and asthma, lung cancer, decreased testosterone and sperm count, and diminished immune function in chronic users?

Cannabis

A child is being treated with oral ampicillin (Omnipen) for otitis media. What should be included in the discharge instructions that the nurse provides to the parents of the client?

Complete the entire course of antibiotic therapy.

While assessing the body temperature of a client, the nurse finds subnormal temperature. Which intervention is beneficial for the client?

Covering the client with blankets

A client who experienced extensive burns is receiving IV fluids to replace fluid loss. The nurse should monitor for which initial sign of fluid overload?

Crackles in the lungs

A client is scheduled to receive intravenous (IV) fluids to be delivered at 80 mL/hr. To adjust the drip rate when administering the IV via gravity, what must the nurse determine?

Drops per milliliter delivered by the infusion set

When caring for a client who is receiving enteral feedings, the nurse should take which measure to prevent aspiration?

Elevate HOB 30-45 degrees

What effect of povidone-iodine does a nurse consider when using it on the client's skin before obtaining a specimen for a blood culture?

Eliminates surface bacteria that may contaminate the culture

A client becomes anxious after being scheduled for a colostomy. What is the most effective way for the nurse to help the client?

Encourage the client to express feelings.

The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia?

End-stage renal disease

When compared with Caucasian patients, which population is at the greatest risk for developing obesity?

Hispanics

Which is a psychological symptom of sleep deprivation?

Hyperexcitability

Which factor can cause early morning awakening and fatigue in older adults?

Hypertension

Which system is involved in the synthesis of chemicals?

Integumentary system

What is evaluation in SOAPIER?

It is the effectiveness of the plan.

A client with a terminal illness creates a legal document that requests that he not be given intravenous nutrition and hydration if he becomes permanently unconscious. What is this document known as?

Living will

Which fluid has an alkaline pH level?

Milk of magnesia

A nurse manager works on a unit where the nursing staff members are uncomfortable taking care of clients from cultures that are different from their own. How should the nurse manager address this situation?

Plan a workshop that offers opportunities to learn about the cultures they might encounter while at work.

An individual is verbally inflicting anguish, emotional pain, and distress on an older adult. Which type of abuse is this?

Psychological

Which statement is true regarding the selection of sites for temperature measurement?

Rectal temperature measurement is contraindicated in clients with traction.

When two nurses are getting an older adult out of bed, the client reports feeling light-headed. The nurse identifies that the client's pulse is stable and the client's color has not changed. What should the nurses assist the client to do?

Sit on the edge of the bed while they hold the client upright.

Which is a characteristic of stage 3 non-rapid eye movement (NREM) sleep?

The vitals slow but remain stable.

A client who is taking rifampin tells the nurse, "My urine looks orange." What action will the nurse take?

This is expected

Which should the nurse's focus be on to decrease health disparities among Hispanic patients?

Translation services

A health care provider 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?

Tubing injection port

A nurse is administering gold salts to a client with the diagnosis of rheumatoid arthritis. For which adverse effect of this drug should the client be monitored?

Kidney damage

Which term is used to describe an individual's generalized expectation about the forms of behavior of individuals of an ethnic group?

Stereotype

An interdisciplinary team of health care professionals is caring for a client with hemiplegia. Which statement about the care provided to the client is correct?

The speech therapist is responsible for improving the client's oral communication.