Evolve fundamentals

How can a nurse best evaluate the effectiveness of communication with a client? 1.Client feedback 2.Medical assessments 3.Health care team conferences 4.Client's physiologic responses

1.Client feedback

A nurse is caring for a newly admitted client in a long-term care facility. The nurse notes that the client has a decreased attention span and cannot concentrate. The nurse suspects which effects of sensory deprivation? 1.Cognitive response 2.Emotional response 3.Perceptual response 4.Physical response

1.Cognitive response

A nurse is caring for a client who has a Hemovac portable wound suction device after abdominal surgery. What is the reason why the nurse empties the device when it is half full? 1.Emptying the unit is safer when it is half full. 2.Accurate measurement of drainage is facilitated. 3.Negative pressure in the unit lessens as fluid accumulates, interfering with further drainage. 4.Fluid collecting in the unit exerts positive pressure, forcing drainage back up the tubing and into the wound.

3.Negative pressure in the unit lessens as fluid accumulates, interfering with further drainage.

The nurse should monitor for which involuntary physiological response in a client who is experiencing pain? 1.Crying 2.Splinting 3.Perspiring 4.Grimacing

3.Perspiring

A client comes to the clinic complaining of a productive cough with copious yellow sputum, fever, and chills for the past two days. The first thing the nurse should do when caring for this client is to: 1.Encourage fluids 2.Administer oxygen 3.Take the temperature 4.Collect a sputum specimen

3.Take the temperature

The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia? (Select all that apply.) 1.Dyspnea 2.Flushed face 3.Chest pain 4.Increased pulse rate 5.Increased blood pressure

2.Flushed face 4.Increased pulse rate

Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibit formation of aqueous humor for a client with glaucoma? 1.Chlorothiazide (Diuril) 2.AcetaZOLAMIDE (Diamox) 3.Bendroflumethiazide (Naturetin) 4.Demecarium bromide (Humorsol)

2.AcetaZOLAMIDE (Diamox)

A nurse is hired to work in a health care facility that has a complete computer-based client information system. The nurse in charge knows that the newly hired nurse is knowledgeable about this system when the nurse says: 1."More medication errors are made when this system is used." 2."It is disappointing that nurses are not allowed to use this system." 3."Client information is immediately available when this system is used." 4."I will have less time to provide direct care to my clients with this system."

3."Client information is immediately available when this system is used."

A nurse cares for a client that has been bitten by a large dog. A bite by a large dog can cause which type of trauma? 1.Abrasion 2.Fracture 3.Crush injury 4.Incisional laceration

3.Crush injury

A nurse assesses a client with dry and brittle hair, flaky skin, a beefy-red tongue and bleeding gums. The nurse recognizes that these clinical manifestations are most likely a result of: 1.A food allergy. 2.Noncompliance with medications. 3.Side effects from medications. 4.A nutritional deficiency

4.A nutritional deficiency

The nurse instructs a client with a new colostomy to avoid foods and drinks that produce a large amount of gas, and specifically to avoid the intake of: 1.Milk 2.Cheese 3.Coffee 4.Cabbage

4.Cabbage

Considering Erikson's developmental theories, a 21-year-old male client who has sustained a spinal injury below the level of T6 will most likely have difficulty with: 1.Mastering his environment 2.Identifying with the male role 3.Developing meaningful relationships 4.Differentiating himself from the environment

3.Developing meaningful relationships

When teaching about aging, the nurse explains that older adults usually have: 1.Inflexible attitudes 2.Periods of confusion 3.Slower reaction times 4.Some senile dementia

3.Slower reaction times

What is a nurse's responsibility when administering prescribed opioid analgesics? (Select all that apply.) 1.Count the client's respirations. 2.Document the intensity of the client's pain. 3.Withhold the medication if the client reports pruritus. 4.Verify the number of doses in the locked cabinet before administering the prescribed dose. 5.Discard the medication in the client's toilet before leaving the room if the medication is refused

1.Count the client's respirations. 2.Document the intensity of the client's pain. 4.Verify the number of doses in the locked cabinet before administering the prescribed dose.

A nurse is caring for an older adult with a hearing loss secondary to aging. What can the nurse expect to identify when assessing this client? (Select all that apply.) 1.Dry cerumen 2.Tears in the tympanic membrane 3.Difficulty hearing high-pitched voices 4.Decrease of hair in the auditory canal 5.Overgrowth of the epithelial auditory lining

1.Dry cerumen 3.Difficulty hearing high-pitched voices

A health care provider prescribes a vitamin tablet that contains vitamin B complex. What should the nurse teach the client? 1.It may turn the urine bright yellow. 2.The daily fluid intake should be increased. 3.The drug should be taken on an empty stomach. 4.It may accumulate in the body if an excessive amount is taken

1.It may turn the urine bright yellow.

An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult the nurse recalls the expected sensory losses associated with aging. (Select all that apply.) 1.Difficulty in swallowing 2.Diminished sensation of pain 3.Heightened response to stimuli 4.Impaired hearing of high-frequency sounds 5.Increased ability to tolerate environmental heat

2.Diminished sensation of pain 4.Impaired hearing of high-frequency sounds

A nurse receives a shift report on four adult clients that are between the ages of 25-55. Which client should the nurse assess first? 1.Male client with a hemoglobin of 15.9 2.Female client on warfarin (Coumadin) with an International Normalized Ratio (INR) of 7.5 3.Female client taking daily calcium supplements with a serum calcium level of 9.4 4.Male client with a blood urea nitrogen (BUN) of 20 and a creatinine of 1.1

2.Female client on warfarin (Coumadin) with an International Normalized Ratio (INR) of 7.5

A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L and a potassium level of 3.6 mEq/L. Based on the lab results and symptoms, what is the client experiencing? 1.Hypernatremia 2.Hyponatremia 3.Hyperkalemia 4.Hypokalemia

2.Hyponatremia

A client reports fatigue and dyspnea and appears pale. The nurse questions the client about medications currently being taken. In light of the symptoms, which medication causes the nurse to be most concerned? 1.Famotidine (Pepcid) 2.Methyldopa (Aldomet) 3.Ferrous sulfate (Feosol) 4.Levothyroxine (Synthroid)

2.Methyldopa (Aldomet)

A 90-year-old female resident of a nursing home falls and fractures the proximal end of her right femur. The surgeon plans to reduce the fracture with an internal fixation device. The general fact about the older adult that the nurse should consider when caring for this client is that: 1.Aging causes a lower pain threshold 2.Physiological coping defenses are reduced 3.Most confused states result from dementia 4.Older adults psychologically tolerate changes well

2.Physiological coping defenses are reduced

A client's serum potassium level has increased to 5.8 mEq/L. What action should the nurse implement first? 1.Call the laboratory to repeat the test. 2.Take vital signs and notify the charge nurse or health care provider. 3.Inform the cardiac arrest team to place them on alert. 4.Take an electrocardiogram and have lidocaine available

2.Take vital signs and notify the charge nurse or health care provider.

A nurse is caring for a client who has paraplegia as a result of a spinal cord injury. Which rehabilitation plan will be most effective for this client? 1.Arrangements will be made by the client and the client's family. 2.The plan is formulated and implemented early in the client's care. 3.The rehabilitation is minimal and short term because the client will return to former activities. 4.Arrangements will be made for long-term care because the client is no longer capable of self-care.

2.The plan is formulated and implemented early in the client's care.

An adolescent is taken to the emergency department of the local hospital after stepping on a nail. The puncture wound is cleansed and a sterile dressing applied. The nurse asks about having had a tetanus immunization. The adolescent responds that all immunizations are up to date. Penicillin is administered, and the client is sent home with instructions to return if there is any change in the wound area. A few days later, the client is admitted to the hospital with a diagnosis of tetanus. Legally, what is the nurse's responsibility in this situation? 1.The nurse's judgment was adequate, and the client was treated accordingly. 2.The possibility of tetanus was not foreseen because the client was immunized. 3.Nurses should routinely administer immunization against tetanus after such an injury. 4.Data collection by the nurse was incomplete, and as a result the treatment was insufficient

4.Data collection by the nurse was incomplete, and as a result the treatment was insufficient

After abdominal surgery a client reports pain. What action should the nurse take first? 1.Reposition the client. 2.Obtain the client's vital signs. 3.Administer the prescribed analgesic. 4.Determine the characteristics of the pain

4.Determine the characteristics of the pain

What should the nurse do initially when obtaining consent for surgery? 1.Describe the risks involved in the surgery. 2.Explain that obtaining the signature is routine for any surgery. 3.Witness the client's signature, which the nurse's signature will document. 4.Determine whether the client's knowledge level is sufficient to give consent

4.Determine whether the client's knowledge level is sufficient to give consent

The nurse is preparing to reinforce teaching a client about self-injection of insulin. Which action by the nurse will increase the effectiveness of the teaching session? 1.Wait until a family member is also present. 2.Assess the client's barriers to learning self-injection techniques. 3.Begin with simple written instructions describing the technique. 4.Wait until the client has accepted the new diagnosis of Type 1 Diabetes Mellitus.

2.Assess the client's barriers to learning self-injection techniques.

Which nursing intervention is most appropriate for a client in skeletal traction? 1.Add and remove weights as the client desires. 2.Assess the pin sites at least every shift and as needed. 3.Ensure that the knots in the rope are tied to the pulley. 4.Perform range of motion to joints proximal and distal to the fracture at least once a day

2.Assess the pin sites at least every shift and as needed.

Which nursing interventions require a nurse to wear gloves? (Select all that apply.) 1.Giving a back rub. 2.Cleaning a newborn immediately after delivery. 3.Emptying a portable wound drainage system. 4.Interviewing a client in the emergency department. 5.Obtaining the blood pressure of a client who is human immunodeficiency virus (HIV) positive

2.Cleaning a newborn immediately after delivery 3.Emptying a portable wound drainage system.

A client is being discharged from the hospital with an indwelling urinary catheter. The client asks about the best way to prevent infection and keep the catheter clean. Which would be appropriate for the nurse to include in the client teaching? 1.Once a day, clean the tubing with a mild soap and water, starting at the drainage bag and moving toward the insertion site. 2.After cleaning the catheter site, it is important to keep the foreskin pushed back for 30 minutes to ensure adequate drying. 3.Clean the insertion site daily using a solution of one part vinegar to two parts water. 4.Change the drainage bag at least once a week as needed

4.Change the drainage bag at least once a week as needed

The unlicensed assistive person (UAP) assigned to the 7 am shift has not been coming to work until 8 am. Nursing care is delayed and assignments are started late. What is the most appropriate action by the charge nurse/team leader? 1.Discuss the issue with a friend from another unit 2.Remind the UAP of the expected start time 3.Report the problem to the Human Resources department 4.Document the information before discussing it with the UAP

4.Document the information before discussing it with the UAP

Refusing to follow the prescribed treatment regimen, a client plans to leave the hospital against medical advice. The nurse recognizes that it is important to inform the client that he or she: 1.Is acting irresponsibly. 2.Is violating the hospital policy. 3.Must obtain a new healthcare provider for future medical needs. 4.Must accept full responsibility for possible undesirable outcomes

4.Must accept full responsibility for possible undesirable outcomes