exam 1

which area of the hands requires special attention before you begin a surgical hand scrub

the area under each fingernail

A patient has tuberculosis (lung infection). Which statement by the nurse indicates a correct understanding of the causes of infection? 1."A pathogen caused this disease." 2."Normal flora is the reason the patient is ill." 3."This microorganism can be seen with the naked eye." 4."Every microorganism can cause an illness."

"A pathogen caused this disease."

The nurse is contributing to the community health presentation about acupuncture. Which statement from a community member indicates a correct understanding of the teaching? 1."Needles are placed along shiatsu to enhance energy pathways." 2."Channels of energy run in regular patterns through and over the body." 3."Pressure is applied to the body to affect the meridians' flow of energy." 4."Classic Japanese medicine allows needles to remove the obstructed energy flow."

"Channels of energy run in regular patterns through and over the body."

The nurse asks a patient, "How are you feeling?" The patient states, "Fine." Which component of this exchange represents feedback in the communication process? 1. Nurse 2. Patient 3. "How are you feeling?" 4. "Fine.

"Fine." This response represents the feedback or a return message.

Which statement would an assertive nurse use during patient care? 1."I do not appreciate that kind of behavior." 2."Do you think you could walk for me today?" 3."It doesn't matter what I do." 4."Who do you think you are talking to?"

"I do not appreciate that kind of behavior." An assertive nurse would say this statement. Individuals with this behavior style show respect for others, express their own feelings in an honest and direct way, and act in a consistent manner that enhances self-worth.

A nurse is teaching a client how to perform personal ileostomy care prior to discharge. The client says, "I don't think that i am going to be able to take care of this myself."

"What part of the ileostomy care are you having trouble with?" - This is a therapeutic response because the nurse is demonstrating acceptance of the client's feelings and is seeking clarification of the client's concerns.

A nurse is caring for a client who has recently found out that she is pregnant. The client says, "I don't think i should tell my partner about the pregnancy."

"You seem uncertain about telling your partner." - This is a therapeutic response because the nurse is reflecting on the client's statement.

The nurse reinforces information with a patient about cough etiquette. Which statement by the patient would indicate successful teaching? Select all that apply. 1."I will use a tissue to cover my mouth and nose when I sneeze." 2."I will cover my mouth with my hand when I cough." 3."I will sneeze into my upper sleeve." 4."I will wash my hands immediately after sneezing."

"I will use a tissue to cover my mouth and nose when I sneeze." "I will sneeze into my upper sleeve." "I will wash my hands immediately after sneezing."

The nurse is caring for a patient who just learned he or she has several months to live. Which response by the nurse is therapeutic? 1. "I think you should get a second opinion." 2. "Well, at least you have time to get things in order." 3. "I think it would be a mistake to get chemotherapy." 4. "I'm so sorry. This must be a shock."

"I'm so sorry. This must be a shock.

The nurse is caring for a patient with osteoporosis and overhears the patient talking about a chiropractic appointment. Which response by the nurse is most therapeutic? 1."You probably shouldn't be going to an appointment like that." 2."That is a good health practice for you to follow." 3."Let the chiropractic practitioner know about your disease." 4."Spinal adjustments are beneficial for health."

"Let the chiropractic practitioner know about your disease."

Which statement by the nurse indicates a correct understanding of charting? 1."My charting can be used against me in a court of law." 2."'Not charted, not done' is always true." 3."Shortcuts are only used if time is short." 4."I use several of my own abbreviations when charting."

"My charting can be used against me in a court of law."

The nurse is collecting data from a patient and wants to know which herbal supplements the patient is taking. Which question would be best for the nurse to ask the patient? 1."Do you take herbal supplements?" 2."What prescribed and over-the-counter herbs do you take?" 3."Are you one of those people who take herbs?" 4."What type of Eastern herbs do you take?"

"What prescribed and over-the-counter herbs do you take?"

Values

Guide decision making and behavior. Develop unconsciously during childhood

the nurse helps the registered nurse (RN) present a staff educational program about Ebola. Which statements from staff members indicate successful teaching? 1."Antibiotics can help cure Ebola." 2."Ebola is transmitted by mosquitoes." 3."People are not contagious until symptoms occur." 4."Following infection control principles will prevent Ebola infection."

"People are not contagious until symptoms occur."

A nurse is giving a series of workshops about health and wellness to a group of older adults at a community center. Which of the following statements from the attendees demonstrate that they understood what the nurse explained about the concept of Health?

- I have my health when I am physically mentally and socially well - Health means wholeness so every aspect of me combines to make a healthy whole self - Health means I do the things that keep me out my best like exercising and eating right

A nurse is giving a presentation to a group of nursing students about distinguishing health promotion and disease prevention activities. Which of the following actions should the nurse include as a specific disease prevention activity?

- wearing sunscreen Outdoors - receiving an influenza immunization - protecting ears from loud noises

A nurse preparing a sterile field knows that the field has been contaminated when, select all that apply

-A cotton ball dampened with sterile normal saline is placed on the field. -The nurse turns to address the patients questions concerning the procedure. -The procedure is postponed for 30 minutes to accommodate the patient.

prior to entering the surgical scrub area, which of the following personal protective equipment (PPE) items do the team members don? (select all that apply)

-protective eyewear -shoe cover -hair cover -mask

you are about to open a sterile pack. place the following steps in the proper sequence for opening the sterile pack

-the flap furthest from your body -the side flaps -the flap closest to your body

The nurse is reinforcing teaching to nursing students about the purposes of documentation. Which information should the nurse include? Select all that apply. 1. Provides continuity of care 2. Obtains reimbursement for care 3. Provides a temporary record of medical care 4. Serves as a record for quality assurance 5. Serves as a legal record

. Provides continuity of care Obtains reimbursement for care Serves as a record for quality assurance Serves as a legal record

The nurse notices the following in a patient's chart: Change furosemide to 20 mg po daily -----------T.O. Dr. Jones/C. Lowe, RN. What type of order did the nurse observe?

. Telephone order

Which responses by the nurse would facilitate communication? Select all that apply. 1."What is causing you the greatest concern at this time?" 2."Tell me more about this pain you are having." 3."I don't think you should divorce your spouse." 4."It will be OK; my father had this surgery and did fine."

1. "What is causing you the greatest concern at this time?" 2. "Tell me more about this pain you are having."

removal of ppe

1. gloves 2. goggles 3. gown 4. mask 5. hand hygene

Putting on PPE

1. gown 2. mask 3. goggles 4. gloves

The nurse is entering a patient's room to provide care. What is the minimum number of seconds the nurse should perform hand hygiene? Record the answer as a whole number. Enter numeral only.

20

Faith

A belief in something or a relationship with a higher power. Faith can be defined by a culture or a religion

You are about to irrigate a patient's open wound. Besides gloves, which other item of personal protective equipment (PPE) must you wear? A sterile gown Goggles A face shield An N95 respirator

A face shield

Which patient situation represents the technical meaning of alternative therapy? 1.A patient uses acupuncture for migraine headaches. 2.A patient uses physical therapy after hip surgery. 3.A patient sees a health-care provider and a chiropractor. 4.A patient sees a conventional practitioner and a naturalist

A patient uses acupuncture for migraine headaches.

Which patient who scheduled an acupuncturist appointment would cause the nurse to be concerned? 1.A patient who experiences vomiting from chemotherapy. 2.A patient who has neck pain. 3.A patient who has carpal tunnel syndrome. 4.A patient who has a prescription for antiplatelet medicine.

A patient who has a prescription for antiplatelet medicine.

The nurse is working in a hospital setting with patients admitted for multiple diagnoses. Which patient does the nurse recognize as requiring a sterile procedure? 1.A patient being treated for chronic obstructive pulmonary disease (COPD) 2.A patient who is prescribed to have an indwelling urinary catheter 3.A patient who needs assistance with eating due to a stroke 4.A patient who is being monitored after an allergic reaction

A patient who is prescribed to have an indwelling urinary catheter

The nurse works on an acute care unit. The nurse is aware of the importance of using sterile technique to prevent contamination and infection. Which patient would the nurse recognize as being least likely to require sterile technique? 1.A patient who is prescribed to receive an intravenous (IV) line for IV fluid 2.A patient who has an abdominal dressing after surgery 3.A patient who needs assistance with changing a colostomy appliance 4.A patient who requires airway suctioning for a pulmonary infection

A patient who needs assistance with changing a colostomy appliance

Which patient would the nurse monitor most closely for a heat stroke?

A patient who practices Bikram yoga.

The nurse is caring for a patient with aphasia. Which health-care team member will the nurse expect to be consulted?

A speech-language pathologist (SLP) will evaluate the patient for the type and level of impairment from aphasia.

The nurse is preparing to perform a sterile procedure on a patient. The nurse is aware of the principles of maintaining surgical asepsis. Which situation will the nurse recognize as a break in sterile procedure? 1.A sterile dressing falls from the wrapper onto the edge of the sterile field. 2.The nurse pours sterile saline into a cup on the sterile field. 3.The surface for the sterile field is at the height of the nurse's waist. 4.The table top is cleaned with alcohol before the sterile field is set up.

A sterile dressing falls from the wrapper onto the edge of the sterile field.

Religion

A system of beliefs practiced outwardly to express one's spirituality

When communicating with a patient, the patient says, "I don't think I can go through with this surgery." The nurse replies by stating, "You don't think you can go through with the surgery?"Which therapeutic communication technique did the nurse use?

Reflection reflects the same words back to the patient.

A newly licensed nurse is reporting to the charge nurse about the care she gave to a client. She states "The client said his leg pain was back, so I check his MR, and he last received pain medication 6hrs ago. The prescription reads every 4hrs PRN for pain, so I decided he needs it. I asked the unit nurse to observe me preparing and administering it. I checked with the client 40 min. late and he said the pain is going away." The charge nurse should inform the newly licensed nurse that she left out which of the following steps of the nursing process? A. Assessment B. Planning C. Intervention D. Evaluation

A. Assessment

A nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired nurse should the nurse identify as appropriate for the planning steps of the nursing process A. I will determine the most important client problems that we should address B. I will review past medical history on the client's record to get more information C. I will go carry out the new prescriptions from the provider D. I will ask the client if the nausea has resolved

A. I will determine the most important client problems that we should address

By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nurse process? A. Reassess the client to determine the reasons for inadequate pain relief B. Wait to see whether the pain lessens during the next 24hr C. Change the plan of care to provide different pain relief interventions D. Teach the client about the plan of care for managing his pain

A. Reassess the client to determine the reasons for inadequate pain relief

A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data (select all that apply) A. Respiratory rate is 22/min with even unlabored respirations B. The client's partner states "He said he hurts after 10 min of walking C. Pain rating is 3 on a scale of 0 to 10 D. Skin is pink, warm, and dry E. The assistive personnel report the client walked with a limp

A. Respiratory rate is 22/min with even unlabored respirations D. Skin is pink, warm, and dry E. The assistive personnel report the client walked with a limp

A patient has a healthcare-associated infection. This term means that the patient Became infected due to compromised immunity Was infected during a therapeutic procedure Inhaled pathogens in a healthcare setting Acquired the infection while hospitalized

Acquired the infection while hospitalized

A nurse is caring for a client who immobile. Which of the following actions should she perform when repositioning the client to avoid injuring her own muscle skeletal system?

Align her feet vertically with her shoulders

the nurse is caring for a patient who develops gas gangrene from Clostridium perfringens. Which strategy should the nurse implement? 1.Reinforce the importance of antibiotics 2.Allow to grieve from loss of body part 3.Prepare the patient for dialysis 4.Administer antihelmintics

Allow to grieve from loss of body part -Amputation of the affected limb is the treatment of choice.

Touch

American: Use during conversations Italian and Latin American: Sign of concern, interest, and warmth Native Americans: Touch is form of aggression

Eye Contact

American: direct eye contact Middle Eastern: avoid with opposite gender Asian: disrespectful Native American: Direct eye contact leads to soul loss

Place the steps of the nursing process in order. Evaluation Assessment Diagnosis Implementation Planning

An easy way to remember the first letter of each step of the nursing process is to use the mnemonic ADPIE: Assessment, Diagnosis, Planning, Implementation, and Evaluation.

Tone of voice

Asian: may use soft voice Italian and Middle Eastern: Loud tone of voice

Which action by the nurse would help decrease misunderstandings between the nurse and a patient from another culture? 1.Ask, "What is your understanding of what we talked about?" 2.Ask, "Do you understand?" 3.Watch for the patient to nod head "yes" when explaining care. 4.Watch for a smile from the patient when explaining care.

Ask, "What is your understanding of what we talked about?"

subjective assessment

Assessment used to obtain information about a client's personal history, as well as his or her occupation, lifestyle, and medical background.

. The nurse is setting up a sterile field. The nurse needs to add sterile dressings to the sterile field. Which actions will the nurse perform if the additional dressings are in peel-apart packages? Select all that apply. 1.Avoid touching sterile items or the drape with bare hands. 2.Expose the two open surfaces of the package toward the sterile field. 3.Open the pack and drop the contents on the drape. 4.Carefully place items on the edge of the drape to the center.

Avoid touching sterile items or the drape with bare hands. Expose the two open surfaces of the package toward the sterile field. Open the pack and drop the contents on the drape.

A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? (select all that apply) A. Writing a prescription for morphine sulfate as needed for pain B. Inserting an NG tube to relieve gastric distention C. Showing a client how to use progressive muscle relaxation D. Performing a daily bath after the evening meal E. Repositioning client every 2hr to reduce pressure ulcer risk

C. Showing a client how to use progressive muscle relaxation D. Performing a daily bath after the evening meal E. Repositioning client every 2hr to reduce pressure ulcer risk

Contact precautions would be mandated for a hospitalized adult patient diagnosed with Hepatitis B. Measles Meningitis Infectious diarrhea

Infectious diarrhea

The nurse is removing personal protective equipment (PPE) after providing care. In which area should the nurse take off the PPE?

Just inside the patient's room

Culture envolves

Knowledge, values, beliefs, morals and law, customs and habits

The nurse is preparing to remove sutures as ordered by the health-care provider. The nurse notes that the suture removable pack has a peel-away covering with a plastic tray to hold the instruments. Which action by the nurse increases the possibility of contamination? 1.Opening the pack by peeling the cover away from the nurse 2.Placing the sterile pack on an alcohol-cleaned surface before opening 3.Carefully dropping the instruments from the package onto a sterile field 4.Donning sterile gloves before touching the instruments in the pack

Carefully dropping the instruments from the package onto a sterile field

Which action by the LPN/LVN indicates a correct understanding of the LPN's/LVN's role in the nursing process? 1.Formulates a nursing diagnosis 2.Develops expected outcomes 3.Performs an admission assessment 4.Carries out interventions

Carries out interventions

Which actions indicate the nurse understands narrative charting? Select all that apply. 1.Charts by exception 2.Charts in chronological order 3.Charts from admission to discharge4 4.Charts concisely and succinctly

Charts in chronological order Charts from admission to discharge Charts concisely and succinctly

Mormonism Health Care Considerations

Children are baptized at age 8 by immersion Clients avoid alcohol, tobacco, and caffiene Last rites include wearing temple clothes for burial Burial is preferred

Islam Dietary Rituals

Clients avoid alcohol and pork Clients can fast during Ramadan

Buddhism death rituals

Clients can request a priest to deliver last rites Chanting is common Brain death is not considered as a requirement for death

Hinduism death rituals

Clients might want to lie on the floor while dying A thread is placed around the neck/wrist The family pours water into the mouth The family bathes the body Clients might want to be cremated

You are washing your hands with a nonantimicrobial soap and water prior to repositioning a patient in bed. During the hand washing procedure, it is important to Make sure that the water is hot Continue for at least 15 seconds Use a liquid soap preparation Remove rings ans watches first

Continue for at least 15 seconds

The licensed practical nurse/licensed vocational nurse (LPN/LVN) is assisting the registered nurse (RN) in preparing a staff presentation about transcultural nursing. Which information should the LPN/LVN contribute to the presentation? Select all that apply. 1. Focuses on one culture 2. Crosses cultural boundaries 3. Is mandated by governmental agencies 4. Includes the culture of the individual nurse 5. Addresses the cultural differences among patients

Crosses cultural boundaries Is mandated by governmental agencies Includes the culture of the individual nurse Addresses the cultural differences among patients

The nurse is preparing to notify the health-care provider that a patient's pain is not relieved by the current pain medication. Which information should the nurse have available? Select all that apply. 1.Number of visitors in the room 2.Current pain assessment 3.Recent vital signs 4.Patient allergies

Current pain assessment Recent vital signs Patient allergies

Which action should the nurse take to show empathy to a patient?

The nurse must keep some emotional distance. Being empathetic will help the nurse conserve his or her own emotional reserves so that the nurse can be available to all who need care.

Which phrase should the nurse use to describe the nursing process? 1.Written plan of care 2.Decision-making framework 3.Another word for critical thinking 4.Validation of information

Decision-making framework

Standard precautions mandate rinsing gloves that become visibly soiled during use. using antimicrobial soap for routine hand washing. disinfecting hands immediately after removing gloves. keeping gloves on when touching environmental surfaces.

Disinfecting hands immediately after removing gloves.

is the process of killing bloodborne pathogens and interfering with the growth of organisms that cause infection.

Disinfection is a cleaning process that commonly uses chlorine bleach. The process can kill pathogens but does not actually sterilize items.

The nurse calls the hospital housekeeping department to clean a room. The previous patient was diagnosed with hepatitis B. Which method of cleaning does the nurse recognize being used to make the room safe for the next patient? 1.Disinfection of all surfaces with chlorine bleach products 2.Sanitization of the floors with commercial cleaning products 3.Sterilization of the bed and over-bed table with steam cleaning 4.Sealing the room and using an antimicrobial gas to kill all pathogens

Disinfection of all surfaces with chlorine bleach products

Hinduism Birth rituals

Do not prolong life Personal hygiene and cleanliness are valued Some are vegitarians

The LPN/LVN is working in home health. Which action should the nurse take? 1.Document how the patient is progressing in follow-up visits. 2.Complete the Outcome and Assessment Information Set (OASIS). 3.Make the first home visit. 4.Perform the initial assessment.

Document how the patient is progressing in follow-up visits.

The nurse is contributing to the plan of care for a patient with vancomycin-resistant enterococci (VRE). Which infection control precautions would the nurse recommend adding to the patient's plan of care? Select all that apply. 1.Don a gown and gloves when giving a bath. 2.Use contact precautions when providing care. 3.Keep a stethoscope in the room. 4.Place the patient in prone position.

Don a gown and gloves when giving a bath. Use contact precautions when providing care. Keep a stethoscope in the room.

To decontaminate your hands with an alcohol-based gel, you rub them together until all of the gel has evaporated and your hands are dry. The primary reason you do this is that Drying provides the full antiseptic effect Residual alcohol can easily stain clothing Excess gel could transfer to the patient Slippery gel can make you drop supplies

Drying provides the full antiseptic effect

Islam Death Rituals

Dying clients confess their sins The body faces Mecca The body is washed and enveloped in a white cloth A prayer is said

Use of space

English: tend to keep distance during communication Italian, French, Spanish, Russian, Latino, Middle Eastern: Prefer closer personal contact and less distance between individuals during communication

The nurse is observing an unlicensed assistive personnel (UAP) who is caring for a comatose patient. Which action by the UAP would require the nurse to intervene? 1. Talking to the patient about the weather 2.Telling the patient that laboratory personnel is here to draw blood 3.Informing the visitors in the room that they can talk to the patient 4. Explaining the care plan for a family member who is in the hospital to the patient

Explaining the care plan for a family member who is in the hospital to the patient

General American Culture Tendencies

Express positive and negative feelings freely Prefer direct eye contact when communicating Address people in a casual manner Prefer a strong handshake as a way of greeting

A patient wants to lower cholesterol and the bad cholesterol levels naturally. Which herbs can help this patient? Select all that apply. 1.Capsaicin 2.Garlic 3.Ginseng 4.Soy

Garlic Ginseng Soy

Assessment

Gather information about the patient's condition

A nurse is giving a presentation about health promotion and disease prevention to a group of young adults at a community college which of the following instructions should the nurse include?

Get a tetanus and diphtheria immunization every 10 years

Diagnosis

Identification of an injury or disease

The registered nurse (RN) is observing the licensed practical nurse/licensed vocational nurse (LPN/LVN) apply a sterile dressing. The LPN/LVN drops part of the dressing on the patient's abdomen and exhibits an intention to use it on the wound. The RN stops the action and opens a new sterile dressing for the LPN/LVN. Which explanation should the RN provide later to the LPN/LVN? 1.If the patient's abdomen had been washed first, the dressing could have been used. 2.If the LPN/LVN had turned the dressing over, the sterile side would touch the wound. 3.If a sterile dressing touches an unsterile object of any kind, the dressing is contaminated. 4.The LPN/LVN could only have used the dropped dressing as a top layer.

If a sterile dressing touches an unsterile object of any kind, the dressing is contaminated.

The World Health organization's who definition of health promotion focuses on the concept of?

Improving control over health

The nurse is assisting a health-care provider during the placement of a subclavian vein catheter. When the health-care provider is putting on sterile gloves, the nurse notices that a finger of the glove touched the patient's gown. Which action should the nurse take immediately? 1.Ask if the health-care provider felt the sterile glove touch the patient's gown. 2.Speak to the health-care provider after the procedure about the observed break in sterility. 3.Stop the procedure and insist that the sterile field be replaced before continuing. 4.Inform the health-care provider that the sterile gloves have been contaminated and need to be changed.

Inform the health-care provider that the sterile gloves have been contaminated and need to be changed.

The nurse is caring for a patient who has a leg infection. Which action indicates the nurse is using sterile technique? 1.Washes hands for 2 minutes 2.Inserts a Foley catheter 3.Removes the patient's lunch tray 4.Uses contact precautions

Inserts a Foley catheter

A nurse can communicate well, manage time effectively, weigh options and consequences, and learn from mistakes. The nurse is demonstrating Wellness in which of the following dimensions of Health?

Intellectual

Spirituality implies connectedness

Intrapersonally: within one's self Interpersonally: with others and the environment Transpersonally: with an unseen higher power

In which order should the nurse conduct the interview process? Ask questions and obtain answers from the patient Introduce self to the patient Thank patient for participating Explain the purpose of the interview

Introduce self to the patient, Explain the purpose of the interview, Ask questions and obtain answers from the patient, Thank patient for participating

Hope

Is a concept that includes anticipation and optimism and provides comfort during times of crisis

Which of the following is an advantage of using alcohol-based gel? Its use take less time than washing with soap/water does It removes gross contamination better than soap/water does Its protective nature reduces the need for frequent hand washing It provides adequate protection before surgical applications

Its use take less time than washing with soap/water does

Barriers to Culturally Responsive nursing care

Language, communication, and perception of time differences Culturally inappropriate tests and tools that lead to misdiagnosis Ethnic variations in drug metabolism r/t genetics Ethnocentrism

Which findings in a patient's history would alert the nurse to a geographical barrier to access health care? Select all that apply. 1.Lives in a rural area 2.Lives in the low-income area of a large city 3.Does not have insurance 4.Lives in a busy metropolitan area

Lives in a rural area Lives in the low-income area of a large city

Which is an appropriate action for the nurse to take when computer charting? 1.Review patient chart that was transferred to another floor for care 2.Allow another nurse to use the password to chart a late entry 3.Log off immediately after charting patient information 4.Copy and paste notes because there has been no change in status

Log off immediately after charting patient information

he nurse spills coffee on a patient's chart while charting. Which action should the nurse take? 1.Write (continued) at the bottom of the damaged nurse's notes followed with signature. 2.Throw the damaged page away and start over. 3.Note on the damaged page that the information will be rewritten. 4.Shred the damaged page after notes are recopied word for word.

Make a notation on the damaged page indicating the portion of the page that will be rewritten and make reference to the recopied page ("Recopied to page 3"). Then, on the new blank page, write "Recopied from page 2" and include the current date and time and signature.

A patient with anxiety may use which complementary and alternative medicine (CAM) therapies to find relief? Select all that apply. 1. Massage 2. Yoga 3. Ginger 4. Chamomile 5. Meditation

Massage Yoga Chamomile Meditation

The nurse works in a hospital setting. The nurse is aware that certain areas are restricted to prevent contamination. Which unit can the nurse be transferred to without needing to follow restriction guidelines? 1.Catheterization laboratories 2.Neonatal intensive care unit 3.Transplantation intensive care 4.Medical care unit

Medical care unit

The nurse is reinforcing teaching with a patient about meditation. The nurse would inform the patient to focus on how many point(s) of reference? Record answer as a whole number.

Meditation is a discipline in which the mind is focused on an object of thought or awareness. It usually involves focusing attention on a single (one) point of reference.

Jehovah's Witness Heath care considerations

Might not accept blood transfusions Clients avoid foods having or prepared with blood Clients can choose burial or cremation

The nurse is using the ISBARR to report a patient problem to the health-care provider. Which information should the nurse include for the B? 1. Dr. Smith, this is Mary Jones, LPN, at Lakeview Hospital. 2. Mr. Allan is having chest pain that is not relieved by medication. 3. The patient's O2 sats are 86% and pulse is 54 and irregular. Skin is clammy. 4. Would you like an ECG done and cardiac enzymes drawn?

Mr. Allan is having chest pain that is not relieved by medication. B stands for background and this is the information that must be provided to the health-care provider.

4 C's of Cultural Assessment

What do you CALL the problem you are having now? How do you COPE with the problem? What are you CONCERNS regarding the problem? What do you think CAUSED the problem?

The nurse is part of a committee that meets to discuss how to perform sterile procedures in a timelier manner. One suggestion is to have sterile packs available that will be procedure specific. Which sterile packs does the nurse recognize as fitting this description? Select all that apply. 1.Neonate circumcision packs 2.Indwelling bladder catheter packs 3.Vaginal examination packs 4.Laceration suturing packs 5.Suture removal packs

Neonate circumcision packs Indwelling bladder catheter packs Vaginal examination packs Laceration suturing packs Suture removal packs

The nurse does not speak the language of the mother who brought her small daughter in for a broken arm, or her young son. The children speak the nurse's language fluently. Which action should the nurse take? 1.Speak to the girl and allow time for the son to interpret. 2.Have the young son relay messages. 3.Obtain an interpreter. 4.Use hand gestures.

Obtain an interpreter.

the nurse is preparing to perform a straight catheterization on a patient with urine retention. When the nurse gathers the sterile equipment needed for the procedure, the nurse notes a discolored line on the packaging. Which action should the nurse take next? 1.Check the expiration date. 2.Feel the package for wetness. 3.Use the equipment. 4.Obtain another package.

Obtain another package.

Judaism Health Care Considerations

On the eighth day after birth, males are circumcised Some practice a kosher diet Someone stays with the body A burial society prepares the body

Which patients would the nurse be caring for who are on droplet precautions? Select all that apply. 1.One who has tuberculosis 2.One who has excessive wound drainage 3.One who has bacterial meningitis 4.One who has rubella (German measles)

One who has bacterial meningitis One who has rubella (German measles)

Interpreters

Only use facility approved medical interpreters

A transgender patient is admitted with leg pain. Which question would be appropriate for the nurse to ask? 1.What happened to make you come to the hospital today? 2.What made you want to change gender? 3.Are you sure this is the gender you want to be for the rest of your life? 4.Do you have a boyfriend?

What happened to make you come to the hospital today?

The nurse is preparing to reinforce teaching with a patient about medications. Which finding would cause the nurse to proceed with the teaching session? 1.Patient states, "My heart is racing." 2.Patient feels feverish and is chilled. 3.Patient just received news of cancer diagnosis. 4.Patient has just finished going to the bathroom.

Patient has just finished going to the bathroom.

Which patient finding would the nurse report as subjective data? 1.Patient vomited green fluid. 2.Patient has stomach cramps. 3.Patient is rubbing abdomen. 4.Patient moans occasionally.

Patient has stomach cramps.

Which action by the nurse is the most important way to prevent health-care-associated infections (HAIs)?

Perform handwashing

Which product can affect the permeability of gloves? Antimicrobial soap and water Alcohol based antiseptic gel Petroleum based hand lotion Water based hand lotion

Petroleum based hand lotion

The nurse is finished using a needle. In which manner should the nurse dispose of the used needle?

Place in a puncture-resistant container.

Which safety measures should the nurse take during implementation? Select all that apply. 1.Read the patient's armband and ask the patient to state name and birthdate. 2Have another staff nurse "talk them through" the skill while in the patient's room. 3.Refer to facility procedures if unsure about a skill. 4.Continue to observe the patient for any problems.

Read the patient's armband and ask the patient to state name and birthdate. Refer to facility procedures if unsure about a skill. Continue to observe the patient for any problems.

The nurse is putting on personal protective equipment to provide care to a patient in transmission-based precautions. Which action should the nurse use to apply the gloves? 1.Place the gloves over the sleeves of the gown 2.Put the first glove on the dominant hand 3.Expose a slight area at the wrists 4.Double-glove

Place the gloves over the sleeves of the gown

A nurse has made a commitment to change his eating habits to optimize his health and wellness. He verify free plans and narrows his choices that was that time I the effect of Lifestyle barely eating quickly at work. Which stage of the transtheoretical model is he in?

Preparation

You are caring for a patient diagnosed with mycoplasmal pneumonia. Droplet precautions have been instituted, so you must Wear a respirator Protect your eyes Use an air filter Wear shoe covers

Protect your eyes

Which patient activity would cause the nurse to wear gloves? 1.Ambulating a patient 2.Providing denture care 3.Taking a radial pulse 4.Filling out a patient's menu

Providing denture care

close-ended questions

Questions that can be answered in short or single word responses.

The nurse observes an unlicensed assistive personnel (UAP) using culturally insensitive practices against a patient of color. The nurse talks to the UAP and later sees the UAP continue the practice. Which action should the nurse take? 1.Talk to the UAP again. 2.Report the incident to the unit manager. 3.Keep a list of the UAP's indiscretions. 4.Inform the other nurses about the UAP's behavior.

Report the incident to the unit manager.

The nurse is using SOAP to chart patient care. Which information would the nurse place after the S? 1.Experiencing impaired gas exchange. 2.Nailbeds bluish, sitting on edge of bed. 3.Notify health-care provider for oxygen. 4.Reports, "Hard to catch breath when I take a deep breath."

Reports, "Hard to catch breath when I take a deep breath."

A nurse is caring for a client who has a long history of abuse of alcohol and opiate opioid analgesics. When counseling this client about the adverse effects of substance abuse the nurse should explain that these patterns reduce the oxygenation of as tissues and organs because they cause

Respiratory depression

The nurse needs to perform a sterile procedure on a patient. When the nurse arrives in the patient's room, the patient is showering. Which action by the nurse is correct? 1.Set up the sterile field and cover it with another sterile cloth before leaving the room. 2.Leave the sterile supplies on the patient's bedside table until needed. 3.Return to the patient's room with sterile supplies after the shower is finished. 4.Set up and sit by the sterile field while waiting for the patient to be ready.

Return to the patient's room with sterile supplies after the shower is finished.

A nurse is counseling a client who says that she attends a book club in her neighborhood regularly. She says it troubles her that no one engages in the discussion with her. Applying Maslow's hierarchy of needs to this client this client needs falls into which of the following levels?

Self-esteem

Place the sequence of the communication process in the correct order. Receiver Information Sender Feedback

Sender, Information, Receiver, Feedback

Which task can the nurse delegate to an unlicensed assistive personnel (UAP)? 1.Taking vital signs 2.Making nursing decisions 3.Writing interventions 4.Evaluating nursing care

Taking vital signs

A patient is experiencing spiritual distress from the loss of a child. Which strategies would the nurse implement? Select all that apply. 1.Sit with the patient for uninterrupted times 2.Say, "This must be hard for you." 3.Say, "Don't be so down. You have other children." 4.Allow the patient to cry 5.Allow opportunity to pray

Sit with the patient for uninterrupted times Say, "This must be hard for you." Allow the patient to cry Allow opportunity to pray

Buddhism dietary rituals

Some are vegetarian Can avoid alcohol and tobacco Might fast on holy days

Christianity dietary rituals

Some avoid alcohol, tobacco, and caffeine Some may fast during Lent Some wish to receive the Holy Communion Some give last rites at death

Christianity birth rituals

Some baptize infants at birth

A patient is anxious. Which therapeutic response should the nurse make? 1. Leave the room quietly. 2. Say, "If you would just calm down, I could help you." 3. Talk to the patient about less stressful things. 4. State, "This must be nerve-racking."

State, "This must be nerve-racking." This response shows empathy about the patient's anxiety and is therapeutic.

Which charting entry best reflects the nurse's evaluation of patient learning for constipation? 1.States that was glad to learn about constipation 2.Nodded head in agreement to increase fluids 3.States, "I will eat more high-fiber foods" 4.Seemed to understand instructions

States, "I will eat more high-fiber foods"

A nurse is caring for a client in an ambulatory Clinic who attended a blood pressure screening event and the Stress Management lecture at a community Fair. His blood pressure was 150 over 94 mmhg at the event, so he saw provider at the clinic and begin therapy with a beta blocker. Soon after, the client had a mild myocardial infarction, after discharge from the hospital, enrolled in a program of cardiac Rehabilitation. Which of the following activities of this client is an example of primary prevention?

Stress Management lecture

The nurse encourages a patient to receive an annual flu immunization to prevent influenza. Which link in the infection chain did the nurse affect? 1.Infectious agent 2.Portal of entry 3.Susceptible host 4.Reservoir

Susceptible host

the nurse is experiencing conflict with an unlicensed assistive personnel (UAP) taking extended break times. According to the DESC method, which statement would the nurse use for the E? 1.You are taking extended break times. 2.What else do I need to do to get your attention? 3.I need you to return from your assigned breaks on time. 4.Taking extended breaks negatively affects patient care and safety.

Taking extended breaks negatively affects patient care and safety. This information represents the E for explain the impact of the behavior.

The nurse is observing an unlicensed assistive personnel (UAP) provide care to patients on transmission-based precautions. Which action by the UAP would cause the nurse to intervene? 1.The UAP wears an N95 respirator for a patient with chickenpox. 2.The UAP leaves the disposable blood pressure cuff in a patient's room who is on droplet precautions. 3.The UAP enters a semi-private room and pulls the curtain because one patient is on droplet precautions. 4.The UAP dons only gloves to provide a bath to a patient on contact precautions.

The UAP dons only gloves to provide a bath to a patient on contact precautions

Ethnocentrism

The belief that one's culture is superior to others. Interfere with the provision of cultural nursing

which statement by the nurse indicates the correct understanding of the mind-body connection in complementary and alternative (CAM) therapy? 1."The focus is on crisis care." 2."The goal is to remove symptoms." 3."The body has the ability to heal itself." 4."The emphasis is on healing the diseased part."

The body has the ability to heal itself."

The nurse is caring for a patient who has a secondary infection. The nurse is most likely caring for which patient? 1.The small male child who has meningitis 2.The male who had a wound infection from Staphylococcus that also has infected the face 3.The older adult who has pneumonia and is receiving antibiotics 4.The female who is taking an antibiotic for a bacterial infection but then develops a yeast infection.

The female who is taking an antibiotic for a bacterial infection but then develops a yeast infection.

After completing a procedure that required donning PPE consisting of a gown, an N95 respirator, a face shield, and gloves, which of the following should the nurse remove first when removing PPE separately? The gloves The gown The face shield The N95 respirator

The gloves

The nurse is working in minor surgery and is setting up a surgical instrument tray. Which item will the nurse send back as a possible source of contamination? 1.The package with an expiration date 2 days away 2.The instrument with a hole in the outer wrapper 3.A clear package with black hash marks on the tape 4.Packages of sutures sterilized with ionizing radiation

The instrument with a hole in the outer wrapper

The nurse is pouring a sterile solution into a small cup on the sterile field. Which action by the nurse is considered incorrect? 1.The solution is poured slowly to prevent splashing onto the sterile field. 2.The label of the solution bottle is opposite the nurse's palm. 3.The solution bottle is held 4 to 6 inches above the cup on the sterile field. 4.The lip of the solution bottle is cleaned by pouring a small amount of liquid into the trash can.

The label of the solution bottle is opposite the nurse's palm.

The nurse is performing a sterile dressing change on a patient. When setting up the sterile field, the nurse spills sterile water on the cloth designating the field. Which action by the nurse indicates the development of a sterile conscience? 1.The nurse moves sterile items away from the wet area on the sterile field. 2.The nurse places a sterile cloth over the area that is wet. 3.The nurse removes the current field and replaces it with a sterile field. 4.The nurse continues with the dressing change because the field is still sterile.

The nurse removes the current field and replaces it with a sterile field.

The nurse is collecting data from a patient about specific information to contribute to the health history. Which type of questions should the nurse use to obtain this data?

The nurse will use close-ended questions as the interview progresses to obtain specific data, such as a health history.

The LPN/LVN is assisting the RN in presenting a community health class for immunizations. The nurses are using the public personal space-distance zone for the presentation. What is the minimum amount of feet the nurses are from the audience?

The personal space-distance zone in the public realm is 12 feet or more.

The nurse works in a long-term care facility. Which reason is the least important for using sterile procedures in this setting? 1.Wound dressings are used and changed. 2.Indwelling urinary catheters are common. 3.As in the hospital, pathogens are a concern. 4.Injectable medications are used regularly.

The presence of pathogens alone is the least important reason for using sterile procedure in any setting. The best way to deal with pathogens is through sterile technique.

The nurse is performing a sterile dressing change for a patient when the nurse determines that a sterile gauze wrap is needed. The nurse has the patient turn on the call light and asks another nurse to bring the gauze. Which action by the second nurse will contaminate the existing sterile field? 1.The second nurse holds the package 4 inches above the sterile field and opens the package. 2.The second nurse reaches across the sterile field to hand the nurse the unopened package. 3.The nurse asks the second nurse to open the package and allow the nurse to reach for the sterile contents. 4.The nurse removes sterile gloves, accepts the package, opens it, and drops the contents on the sterile field.

The second nurse reaches across the sterile field to hand the nurse the unopened package.

Ethnicity

The shared identity, bond, or kinship people feel with their country of birth or place of ancestral origin that affects culture

The nurse is aware of the principles of surgical asepsis and the conditions that define contamination. Which condition does the nurse recognize as remaining uncontaminated when liquid is spilled on a sterile field? 1.The sterile drape covering the table is backed with a waterproof material. 2.The top of the table and the liquid have both been sterilized. 3.The procedure is ending and the exposure time is limited. 4.The attending health-care provider is aware and orders preventive antibiotic therapy.

The sterile drape covering the table is backed with a waterproof material.

The nurse is preparing to start an intravenous line (IV) on a patient who is confused. When the nurse starts to pierce the skin, the patient pulls away. The nurse is not sure if the patient's arm brushed the IV catheter. Which action should the nurse take? 1. Wipe the opened catheter with a sterile alcohol wipe and attempt to start the IV. 2.Ask the patient if any sharp sticks were felt on the arm when the patient pulled away. 3.Examine the patient's arm to validate if the catheter was touched by the patient. 4.Throw the catheter in the sharps box and open a second catheter.

Throw the catheter in the sharps box and open a second catheter.

The nurse is caring for a patient of the Islamic faith. Which action should the nurse take? 1.Treat the patient with dignity. 2.Include biases in care. 3.Focus solely on tasks. 4.Be indifferent to religious aspects of care.

Treat the patient with dignity.

The nurse writes the following in a patient's chart: Heart tones strong. However, the nurse meant to write weak rather than strong. What should the nurse do? 1.Scratch out strong and add weak. 2.Place correction fluid over strong and then write weak. 3.Write weak over the word strong. 4.Make a single horizontal line through strong and initial it.

Upon making an incorrect entry, mark a single horizontal line through the incorrect word or phrase. Write "mistaken entry" and initials just above the incorrect words. Then proceed with the correct entry.

the nurse is caring for a resident in a long-term care facility. Which action should the nurse take when charting care about this resident? 1.Sign just the last entry on the page. 2.Use a specific time for each entry. 3.Write illegibly with a black pen. 4.Chart the procedure before it is done.

Use a specific time for each entry.

The nurse is caring for a patient who has tuberculosis. Which infection control precaution should the nurse implement? 1.Wear a mask and gown. 2.Leave the patient's door open. 3.Use an airborne infection isolation room. 4.Reuse gloves as needed.

Use an airborne infection isolation room.

The nurse is caring for a patient with methicillin-resistant Staphylococcus aureus (MRSA). Which medication would the nurse observe on the patient's medication administration record? 1.Penicillin 2.Vancomycin 3.Acyclovir 4.Metronidazole

Vancomycin

The nurse is caring for a patient with Clostridium difficile. Which action is priority?

Wash hands with soap and water

After assisting a newly admitted patient in removing his shoes and outerwear, you notice what appears to be soil on your hands. You Cleanse your hands with an alcohol-based gel. Wash your hands with soap/water Brush off the soil against a cloth surface Use a wet paper towel to remove the soil

Wash your hands with soap and water

Islam Birth rituals and health care considerations

Women must be cared for by female providers Women often cover head and body when in presence of males Have strict hand washing rules Must pray five times a day facing Mecca

Which patient findings would the nurse classify as verbal communication? Select all that apply. 1.Nodding head 2.Writing a note 3.Reporting pain 4.Pointing to wound

Writing a note Reporting pain

A nurse is caring for a client who had a spontaneous abortion at 9 weeks of gestation. The nurse walk into the client's room and finds her crying uncontrollably. Which of the following is a therapeutic response? a. "It is hard to deal with a pregnancy loss. Here is the number of a local support group that you could attend." b. "When a pregnancy ends spontaneously, there is often something wrong with the fetus." c. "You are young and will have other children." d. "The best thing for you is to go home and try again."

a. "It is hard to deal with a pregnancy loss. Here is the number of a local support group that you could attend." - This is a therapeutic response because the nurse is offering empathy and providing information regarding a support network that the client can access.

A nurse is caring for an older adult client who dies during the night with his wife at this side. The wife says to the nurse, "I can't believe he's gone." Which of the following is a therapeutic response by the nurse? a. "It must be hard to accept that this has happened." b. "His suffering is over now. He is in a better place." c. "I know how you are feeling. I just lost my father." d. "He lived a really long and full life."

a. "It must be hard to accept that this has happened." - This is a therapeutic response because the nurse is restating what the client has said, which allows the partner to hear what the nurse has received from her communication.

A nurse is caring for a client with diabetes who is to receive hemodialysis. The client says to the nurse, "I don't even know why I'm doing this. There is no cure." Which of the following is an appropriate nursing response? a. "It sounds as though you have given up." b. "Dialysis will help you live longer." c. "You shouldn't complain. You are fortunate to have this option available to you." d. "There is always a chance that, through research, a cure will be found."

a. "It sounds as though you have given up." - The nurse is using the therapeutic communication technique of restatement to encourage the expression of feelings.

A nurse is caring for a 13 y.o who is admitted for an emergency appendectomy. While doing the preoperative teaching, the client asks, "Will I have a large scar from the surgery?" Which of the following is a therapeutic response? a. "It will be small enough so it won't show when you're wearing a bathing suit." b. "That isn't our biggest concern right now. Let's get you well first." c. "Don't worry. Scars fade a lot in just a few months." d. "Did your friends tell you that you will have a big scar?"

a. "It will be small enough so it won't show when you're wearing a bathing suit." - This is a therapeutic response because the nurse is providing information specific to the client's concern. The nurse recognizes that body-image is an important issue for adolescents. This response allays fears that the client might be having.

An emergency department nurse takes a telephone call from a client who reports "I have just taken 100 Elavil tablets to kill myself." The client is crying and says, "I want to die. I have no reason to live." Which of the following responses by the nurse is appropriate? a. "Please stay on the phone with me so we can talk about your feelings." b. "Why do you think you have no reason to live?" c. "How do you feel about what you have just done?" d. "I'm sure things are not as bad as they seem to you now."

a. "Please stay on the phone with me so we can talk about your feelings." - This is a therapeutic response because the nurse has given the client opportunity to share his feelings. The nurse is also encouraging the client to stay on the phone so that emergency personnel can get to the client's home.

Evaluation

analysis, document patient response and sings and symptoms

A nurse is caring for a client who is a victim of rape. The client says to the nurse, "I feel so humiliates. I don't want anyone to know what happened to me." Which of the following is a therapeutic response? a. "You should not be so hard on yourself. It was not your fault." b. "Are you saying that you are fearful about what others will think?" c. "This is a normal feeling after what has happened to you." d. "The best thing for you to do is to put this out of your mind and think positive thoughts."

b. "Are you saying that you are fearful about what others will think?" - The nurse is using the therapeutic response of clarification. This response helps the client to clarify her own thoughts.

When approached by a nurse, a client with major depressive disorder says, "Don't bother me. Find someone else to talk with. I don't have anything worth saying. go find someone you can help." Which of the following is a therapeutic response? a. "I have the feeling that I upset you. Don't you want to talk to me?" b. "I would like to sit quietly with you for a while." c. "I'm assigned to take care of you, so I intend to spend time with you." d. "OK. I'll go now and be back in a half-hour."

b. "I would like to sit quietly with you for a while." - This is a therapeutic response because the nurse is offering self. This response lets the client know that the nurse has the desire to understand.

A nurse is assessing a client. For which of the following client statements should the nurse use a close-ended question? a. "I wonder what the world would be like without me." b. "I'm bleeding." c. "I am just so sad today." d. "I don't like the way that person is looking at me."

b. "I'm bleeding."

A client with a suspected brain tumor is scheduled for a CAT scan. When the procedure is explained, the client expresses fear of entering the enclosed space of the scanner. Which of the following responses by the nurse is appropriate? a. "The procedure only takes a few minutes to complete." b. "Let me review some breathing exercises with you." c. "I can ask the doctor to prescribe a sedative for you." d. "This is a routine test so there is no reason to worry."

b. "Let me review some breathing exercises with you."

A nurse is caring for a client with leukemia. The client says to the nurse, "The doctor told me that my condition is too severe to be treated successfully, and I am no longer a candidate for chemotherapy. I guess I don't have long to live." Which of the following responses by the nurse is therapeutic? a. "Having a positive attitude can help you." b. "Let's talk about how you are feeling about this information." c. "Have you considered getting a second opinion?" d. "How long do you feel that you have left to live?"

b. "Let's talk about how you are feeling about this information." - This is a therapeutic response because the nurse is using the exploring technique. This technique allows the client the opportunity to express his feelings regarding the prognosis.

A nursing assistant is caring for a client who is unconscious. While bathing the client, the nursing assistant describes the weather and chats about current events. The client's wife says to the nurse, "Why does the nursing assistant talk to my husband? He's unconscious." The nurse should respond by stating, a. "I'll speak to the nursing assistant about it. Your husband should not be stimulated like that." b. "I'm really not sure why the nursing assistant is talking to him. Perhaps you should ask." c. "Clients like your husband, who are unconscious, may still be able to hear." d. "The nursing assistant must not realize that your husband cannot hear."

c. "Clients like your husband, who are unconscious, may still be able to hear." - The client who is unconscious might still be able to hear even if unable to respond. A client who is unconscious also requires an appropriate level of stimulation.

When nurse is making morning rounds, a client says, "I almost died last night." Which of the following is a therapeutic response by the nurse? a. "Are you feeling okay now?" b. "Clients do have dreams that they die when they are hospitalized." c. "That must have been frightening for you. Tell me more about it." d. "You made it through the night."

c. "That must have been frightening for you. Tell me more about it." - This therapeutic response directly addresses the client's concern. The nurse uses the communication tool of empathy in responding to this client's concerns and clarifies the client's feelings.

A client is scheduled for a lumbar puncture to rule out bacterial meningitis and tells there nurse that he is fearful of becoming paralyzed from the needle being placed in the spinal column. Which of the following is a therapeutic response by the nurse? a. "The danger of hitting the spinal cord is minimal. You will be lying very still with you back in an arched position." b. "What concerns you the most about this procedure?" c. "The needle is inserted below the third lumbar vertebrae, well below the point at which the spinal cord ends." d. "Your doctor is very skilled in this procedure and it's highly unlikely that a mistake would be made."

c. "The needle is inserted below the third lumbar vertebrae, well below the point at which the spinal cord ends." - This is a therapeutic response that provides information that specifically addresses the client's concerns and helps to decrease anxiety and fears.

After teaching a client how to perform personal colostomy care prior to discharge, the client says to the nurse, "I don't think that I am going to be able to take care of this myself." Which of the following is an appropriate response by the nurse? a. "In time, you will become better at this than I am." b. "Don't worry about it. Most clients feel like that at first." c. "What part of the colostomy care are you having trouble with?" d. "A home health nurse will be visiting you, so if you have any problems, this nurse can help you."

c. "What part of the colostomy care are you having trouble with?"

An adult child has come to take a parent home from the hospital following a colon resection. The adult child tells the nurse, "I don't know how I am going to take care of my parent now." Which of the following is an appropriate response? a. "A home health nurse will be stopping by tomorrow. If you have any questions, you can ask then." b. "Your parent has been taught to care for the colostomy independently." c. "What part of your parent's care you concerned about?" d. "It is quite simple. I'll make sure that the colostomy bag is clean before your parent leaves."

c. "What part of your parent's care you concerned about?" - This is a therapeutic response because the nurse is using clarification to address the son's immediate concerns about caring for his parent.

Buddhism Birth rituals and health care decisions

can refuse care on holy days can refuse analgesics or strong sedatives

Etiology

cause of disease

a nurse preparing to flush and change the dressing on a patient's central venous catheter should understand that the primary purpose for performing this intervention using surgical asepsis is to

control the introduction of micro-organisms at the catheter site

the goal of surgical asepsis is to

create and maintain a micro-organism-free environment

A nurse is caring for a client following a spontaneous abortion. The client is cry8ing and says to the nurse, "I tried to get pregnant for so long. My husband and I wanted this baby so much. Now what will we do?" Which response by the nurse is appropriate? a. "There are many options available, such as genetic counseling." b. "You can have another baby soon." c. At this time, your husband's support is really important." d. "Are you feeling overwhelmed?"

d. "Are you feeling overwhelmed?" - The nurse is using the technique of clarification to gain a better understanding of the client's thoughts and is expressing understanding with this therapeutic response.

An adolescent client is just diagnosed with testicular cancer. When the nurse asks the client a question, he angrily spits in there nurse's face. Which response by the nurse would be appropriate? a. "I will come back to change your linens when you are feeling better." b. "Your parents call every day and I will have to tell them about your behavior." c. "The nurses will not want to take care of you if you treat us this way." d. "That behavior makes me very angry, and I will not tolerate it."

d. "That behavior makes me very angry, and I will not tolerate it."

A client who has just been diagnosed with cancer tells the nurse, "I would rather be dead than go through the treatment for cancer." Which of the following is an appropriate response by the nurse? a. "That wouldn't be fair to your family, would it?" b. "How can you feel that way when you have so much to live for?" c. "Why don't you talk to your doctor about your feelings?" d. "What is it about the cancer treatment that concerns you?"

d. "What is it about the cancer treatment that concerns you?" - This is a therapeutic response because the nurse is asking a broad question that allows the client to explore thoughts and feelings.

An older adult client is admitted to the hospital for surgery for a fractured hip. The client says to the nurse, "I guess I've lived long enough, and it's my time." Which is the therapeutic response by the nurse? a. "The doctors and nurses are going to take good care of you while you are here. There's nothing to worry about." b. "This is just a minor setback. You will be on your feet in no time." c. "You are in really good shape for your age." d. "You feel that your life is ending?"

d. "You feel that your life is ending?" - This is a therapeutic response because the nurse is using restatement to promote communication. This response addresses the client's immediate concern about not living any longer.

A nurse is caring for an adolescent client in the community health center who has a positive HCG test. She tells the nurse, "I don't think I can tell my parents that I am pregnant." Which of the following is an appropriate response? a. "Do you think you may terminate the pregnancy?" b. "Give them a chance; your parents will understand." c. "You must tell your parents as soon as possible." d. "You seem frightened to tell you parents."

d. "You seem frightened to tell you parents." - This is a therapeutic response because it provides the client with an opportunity to express any concerns or fears.

Planning

developing goals and preparing to achieve those goals

during surgical handwashing, the hands are kept above the elbows to

encourage water and soap to flow away from the clean hands

The LPN/LVN reviews the nursing diagnosis written on the care plan: Risk for infection related to a break in the skin. The italicized phrase represents which component of the nursing diagnosis? 1.Signs and symptoms 2.Defining characteristics 3.Etiology 4.Problem

etiology refers to the causative factor(s) and is connected to the diagnostic label by the words "related to."

Implementation

experiment, organize and manage patient care, performing nursing action, educate patient

The nurse is asked by a patient about reflexology. The nurse would inform the patient that which area of the body will be the focus of treatment? 1.Hand 2.Foot 3.Back 4.Chest

foot

when donning sterile gloves using the open-gloving method, it is important to remember to

grasp only the inside of the glove with your ungloved hand

When opening a sterile pack, which of the following actions would compromise the sterility of the instruments and supplies inside the pack?

holding the sterile pack below waist or table level

A nurse is caring for a client who has suspected brain tumor and is scheduled for a computerized axial tomography scan (CAT). When the procedure is explained, the client expresses fear about entering the enclosed space of the scanner.

let me review some breathing exercises with you - It is not uncommon for a client who has claustrophobia to be fearful of entering the enclosed space of the CT scanner. To help minimize anxiety, the nurse should encourage the use of relaxation techniques, such as breathing exercises, prior to the procedure.

Assesment

problem, what you think is going on

open-ended questions

questions that allow respondents to answer however they want

SOAP acronym

subjective, objective, assessment, plan

a nurse donning sterile gloves knows that the proper technique for gloving the dominant hand prevents contact between the contaminated hand and the noncontaminated glove because

the inner edge of the cuff will lie against the skin and thus will not be sterile

Plan

treatment, what you are going to do

The nurse is beginning care with a patient who was just admitted with stroke. What is essential for the nurse to develop in the nurse-patient relationship?

trust

objective assessment

vital signs, physical exam findings, lab data, other diagnostic testing, what you see

while waiting for a sterile procedure to begin, how do you position your hands and arms

with your hands clasped together in front of your body above waist level

A nurse is caring for an adolescent client who was recently diagnosed with testicular cancer. When the nurse asks the client a question, he angrily spits in the nurse's face.

you seem to be very upset - This is a therapeutic response because it allows the client to explore his feelings and can de-escalate the situation.