Exam 2

The nurse is caring for a client who is receiving a prescribed intravenous (IV) infusion of an antibiotic to treat an infection. The client asks the nurse, "Can I just take a pill?" What is the best response by the nurse? "The physician can control the dose of medication you receive through IV." "The IV infusion will treat your infection faster." "An IV infusion maintains a therapeutic level of the medication in your blood." "Oral antibiotics are not as effective as IV infusions."

"An IV infusion maintains a therapeutic level of the medication in your blood."

A patient is preparing for discharge following hip surgery and the patient will likely require extensive physiotherapy. What assessment question should the nurse prioritize? -"How long do you expect to need physiotherapy?" -"Are you able to pay for the costs of your physiotherapy treatments?" -"Do you understand the difference between a physiotherapist and a physician?" -"Before your surgery, had you ever had physiotherapy?"

"Are you able to pay for the costs of your physiotherapy treatments?"

The nurse is caring for a client who has a heavy exudating wound that needs autolytic debridement. Which wound dressing/product is most appropriate to use on the wound? -An alginate dressing -Transparent film -A hydrogel dressing -An antimicrobial dressing

An alginate dressing

A nurse is reviewing the plan of care for a client and notes the following: "The client verbalizes three signs of hypoglycemia to the staff accurately before discharge." The nurse interprets this statement as a(n): -Nursing Diagnosis -Outcome criteria -Intervention -Client outcome

Outcome criteria

A team of nurses is caring for a client with tuberculosis. They have not been fitted an N95 respirator. How will the team proceed with care? -Refrain from providing care until a nurse who has been fitted arrives. -Use a regular mask and continue to provide care as usual. -Utilize a powered air, purifying respirator (PAPR). -Enter the room as normal, but maintain a 3-foot distance from the client.

Utilize a powered air, purifying respirator (PAPR).

The nurse is caring for a 7-year-old client with varicella. Which precautions will the nurse begin? airborne droplet contact none

airborne

The nurse is caring for an older adult with influenza. Which precautions will the nurse begin? -airborne -droplet -contact -none

droplet

Which method of charting did the nurse used to document "Fluid Volume Overload. On assessment client's lower limbs oedmatous ++. Affected leg elevated and furosemide 40 mg intramuscular given. No signs of deep vein thrombosis noted. Limbs now oedema +"? pie charting focus charting narrative charting exception charting

focus charting

Of all the benefits of nursing diagnoses, which one is probably the most important to nurses? -defining the domain of nursing practice -informing patients of their care -improving communication among nurses -structuring curricular content

improving communication among nurses

A client arrives at a crisis center in a state of bipolar mania. The client has a flight of ideas and it is difficult for the nurse to obtain an adequate intake assessment. Which statement or question will elicit the most specific information? "Describe why people in glass houses should not throw stones." "Tell me about a time in your life when you were happy." "What do believe caused this current manic episode?" "Are you allergic to any medications?"

"Are you allergic to any medications?"

A nurse helps a client who has cystic fibrosis prepare a standalone personal health record. Which statement by the nurse best explains this type of information? -"You can fill in information from your own records and store it on your computer or the Internet." -"You can link your record to a specific health care organization's electronic health record system." -"Your health care provider is obligated to read your personal health record and share it with your insurance provider." -"Your entire health care team may access and securely share your vital medical information electronically."

"You can fill in information from your own records and store it on your computer or the Internet."

A nurse is preparing to administer a rectal suppository to an adult client. How many inches should the nurse to insert the suppository? -3 inches (8 cm) -1 inches (2.5 cm) -2 inches (5 cm) -5 inches (13 cm)

3 inches (8 cm)

Which items reflect the assessment phase of the nursing process? Select all that apply. -Asking the patient"How would you rate your pain?" -The nurse assists the client with coughing and deep breathing every hour -The client's abdomen is firm and distended with hypoactive bowel sounds -The client states: "I rarely sleep more than 6 hours" -The nurse and the client determine a tolerable pain level

Asking the patient"How would you rate your pain?", The client's abdomen is firm and distended with hypoactive bowel sounds, The client states: "I rarely sleep more than 6 hours"

The home health nurse caring for a client with limited eyesight notes that the client's route to the bathroom is cluttered. What is the most effective way for the nurse to ensure the client's long-term safety? Remove all the cluttered objects from the pathway to the client's bathroom. Instruct the client about the need to keep the walkway to the bathroom clear. Assist the client to identify strategies to promote safety in the home. Assign a home health aide to perform housekeeping duties.

Assist the client to identify strategies to promote safety in the home.

A nurse is conscientious about implementing the principles of asepsis while providing care for clients. The principles of asepsis include which of the following? -Visibly clean objects are considered to be sterile. -It is impossible to completely eliminate microorganisms from an object. -Blood and body fluids are major reservoirs for microorganisms. -All nonsterilized surfaces are considered to be equally contaminated.

Blood and body fluids are major reservoirs for microorganisms.

The nurse is planning care for a college student with a new diagnosis of inflammatory bowel disease. The client lives in the dormitory on campus and eats meals in the cafeteria. Which is the most appropriate long-term client outcome? -Client will maintain nutritional intake without pain or diarrhea -Client will talk with campus cafeteria manager about identifying safe meals Client will identify foods that trigger uncomfortable symptoms -Client will learn to cook foods that meet personal nutritional needs

Client will maintain nutritional intake without pain or diarrhea

What steps must the nurse take to assure accurate nursing diagnoses? Select all that apply. -Collect complete and accurate data -Ask the client to identify problems that concern the client -Plan identical nursing diagnosis for clients with the same medical diagnosis -Distinguish normal from abnormal data -Select nursing diagnosis that address health problems that can be changed

Collect complete and accurate data,Ask the client to identify problems that concern the client, Distinguish normal from abnormal data

A client with multiple leg fractures following a motor vehicle accident tells the nurse, "I am going crazy here. I have to wait 2 months before I can practice walking, again." What is the priority nursing diagnosis? -Impaired Walking -Activity Intolerance -Deficient Diversional Activity -Disturbed Body Image

Deficient Diversional Activity

The thin, outermost layer of the skin is continuously shed in a process called: -Dermabrasion -Dermatitis -Exfoliation -Desquamation

Desquamation

A client has a nursing diagnosis of Possible Spiritual Distress. What is the most appropriate nursing intervention? -Seek out the client's pastor for help. -Discuss spirituality with the client. -Offer to pray with the client. -Leave the client alone for privacy.

Discuss spirituality with the client.

What action should the nurse take when giving an intramuscular injection using the Z-track method? -Use a needle at least 1 inch (2.5 cm) long. -Apply pressure to the injection site. -Inject the medication quickly, and steadily withdraw the needle. -Do not massage the site because it may cause irritation.

Do not massage the site because it may cause irritation.

While assessing a client, the nurse notices that the client seems to be distracted from the questions being asked. The nurse attempts to identify factors that may be affecting the communication. What would the nurse identify as an internal influencing factor? -Noise -Privacy -Ambience -Experience

Experience

A client who is scheduled for coronary angioplasty is concerned if the surgery is safe and wonders whether it would be beneficial to him. Which nursing diagnosis relates to this client's condition? -Ineffective Coping related to anxiety and fear of surgery -Anxiety related to fear of death during surgery -Fear related to potential risk and surgical outcomes -Knowledge Deficit: treatment regimen related to surgical outcomes

Fear related to potential risk and surgical outcomes

A nurse is caring for clients with alterations in mobility. Which nursing interventions are recommended for these clients? Select all that apply. -For increased cardiac workload, instruct the client to lie in the prone position -For ineffective breathing patterns, encourage shallow breathing and coughing -For orthostatic hypotension,, have the client sleep sitting up or in an elevated position -For impaired physical mobility, perform ROM exercises every 2 hours -For constipation, increase fluid intake and roughage -For impaired skin integrity, reposition the client in correct alignment at least every 1 to 2 hours

For orthostatic hypotension,, have the client sleep sitting up or in an elevated position, For constipation, increase fluid intake and roughage

A nurse is providing care for a patient who has undergone a partial foot amputation for the treatment of osteomyelitis (bone infection). The nurse observes that the patient will not look at her foot when the nurse changes the dressing. How should the nurse best follow up this observation? -Implement interventions aimed at improving the patient's self-esteem. -Gather more data to better understand the patient's behaviour. -Attempt to help the patient accept the change in her body image. -Teach the patient that her amputation does not need to affect her quality of life.

Gather more data to better understand the patient's behaviour.

The nurse has provided a hot pack to a client who has been experiencing neck pain. According to the gate control theory of pain transmission, why is this intervention likely to be effective? - Heat stimulates the large-diameter fibers that inhibit pain transmission. -Heat and pressure open the gates that conduct pain-relieving endorphins to the brain. -Heat overwhelms the small-diameter pain fibers and they stop transmitting pain signals. -Heat opens nerve gates so that they can transmit pain-inhibiting enkephalins.

Heat stimulates the large-diameter fibers that inhibit pain transmission.

A nurse is adding a sterile solution to a sterile field and has just opened the bottle according to manufacturer's directions. What is the next step? -Touch the tip of the bottle to the sterile container to start the flow of the solution, then pour it into the container directly from the top of the container edge. - Hold the bottle outside the edge of the sterile field with the label side facing the palm of the hand and prepare to pour from a height of 4 to 6 inches (10 to 15 cm). -"Lip" a new or old bottle of solution before pouring it and hold the solution with the label facing out from a height of 4 to 6 inches (10 to 15 cm). -Hold the bottle inside the 1-inch edges of the sterile field with the label side facing the palm of the hand, then pour from a height of 2 to 4 inches (5 to 10 cm).

Hold the bottle outside the edge of the sterile field with the label side facing the palm of the hand and prepare to pour from a height of 4 to 6 inches (10 to 15 cm).

A nurse needs to instill eye medication in a client with conjunctivitis. Which action should the nurse take to distribute the medication over the surface of the eye? -Gently rub the client's eyelids -Make a pouch in the lower eyelid -Instill the eye drops in the lower lid and have the patient blink -Instill medication drops in the upper eyelid

Instill the eye drops in the lower lid and have the patient blink

The nurse is caring for a client with terminal bone cancer. The client states, "My pain is getting worse and worse and the morphine doesn't help anymore." The nurse determines the client's pain is -Acute -Chronic -Diffuse -Malignant

Malignant

The nurse is caring for Mr. H., a 35-year-old man who is hospitalized following a motorcycle accident. He has a traumatic brain injury. The nurse is working with Mr. H. on self-care behaviors. The following would help the nurse to assess the success of the nursing interventions except which of the following? - Check with the client to ensure personal goals are met. -Model self-care behaviors for the client. -Collect data on the number of self-care activities performed that day. -Ask client to discuss his goals for the day at the start of the shift.

Model self-care behaviors for the client.

The nurse manager is assessing the unit for proper work ergonomics. Which finding will require immediate intervention by the nurse manager? -Equipment is positioned 25 degrees away. -Chairs have firm back support. -Nonglare lighting is present. -Nurses and unit assistants use telephones with handsets.

Nurses and unit assistants use telephones with handsets.

A nurse is assessing a client admitted to the hospital with reporting left-sided weakness and difficulty speaking. Which assessment contains the data that best represent a nursing assessment? -Neurologic examination reveals partial paralysis and aphasic speech -Brain scan shows evidence of a clot in the middle cerebral artery -Patient is unable to communicate basic needs and cannot perform hygiene measure with left hand -Left sided weakness and speech deficit indicate probably stroke

Patient is unable to communicate basic needs and cannot perform hygiene measure with left hand

Which nursing actions reflect the implementing step of nursing process? -Selecting culturally sensitive nursing interventions -Determining the client's response to nursing interventions -Providing health education to reduce health risks -Not using evidence based interventions for the client

Providing health education to reduce health risks

A nurse just reported to the oncoming shift that she had failed to do an ordered dressing change. She reported to the nurse manager that this was the second time this week she had not had time to do the dressing change. The nurse manager recognized that the nurse normally was very punctual and was known to provide good care for her clients however the unit census had been very high on this particular week. The nurse manager knows that quality care must be provided and reports this occurrence as what type of quality approach? -Quality by inspection -Quality by opportunity -Quality by design -Quality by promotion

Quality by opportunity

A nurse in the ICU (intensive care unit) has been assigned to care for a client who was seriously injured during a gang rape. The nurse was raped 6 months ago and feels that she will be too upset to care for the client properly. How should the nurse deal with the assignment? Recognize her limitations and ask for another nurse to be assigned. Recognize that she may be faced with this issue again and care for the client. Recognize her limitations and ask another nurse to assist her if she becomes too emotional. Recognize the issue and care for the client to the best of her ability.

Recognize her limitations and ask for another nurse to be assigned.

A nurse documents the following diagnosis for a hospitalized client: "Risk for Imbalanced Nutrition: More Than Body Requirements." What is the major goal of interventions for a risk diagnosis? -Reduce or eliminate contributing factors -Prevent the problem -Collect additional data -Promote higher level wellness

Reduce or eliminate contributing factors

The nurse is preparing to implement plans of care with several clients. Which action would be inappropriate for the nurse to perform? -Ask the English-as-a-Second-Language (ESOL) client to state in his or her own words what it means to be NPO. -Seek input from the family of how the client with aphasia normally communicates at home. -Respond to the postoperative client's question that baths are given only in the morning. -Request that family members provide ethnic/cultural foods of the African client's liking.

Respond to the postoperative client's question that baths are given only in the morning.

Which action should the nurse take when client data indicate that the stated goals have not been achieved? -Collect more data for the database. -Review each preceding step of the nursing process. -Implement a standardized plan of care. -Change the nursing orders.

Review each preceding step of the nursing process.

A health care facility plans to evaluate and revise the plan of care for a client based on the client's health care records. The physician, dietitian, and nurse involved in the client's care are required to collate all of the information for easy access. Which style would the nurse conclude that the facility is following in order to record the client details? -FOCUS charting -Narrative charting -PIE charting -SOAP charting

SOAP charting

The National Formulary (NF) is a list of medications which are regulated by the U.S. government. It describes medications based on certain categories. Which category does the National Formulary not describe? Source Physical properties Purity Side effects

Side effects

A nurse is interviewing a new client admitted to the hospital for surgery. Which action would the nurse perform in the introductory phase of the interview? -The nurse assesses the client's comfort and ability to participate in the interview. -The nurse recapitulates the interview, highlighting important points. -The nurse ensures the environment for the interview is comfortable and private. -The nurse gathers all the information needed to form the subjective database.

The nurse assesses the client's comfort and ability to participate in the interview.

Which best describes an element of the nurse-client relationship? -The nurse self-discloses only what is necessary for the client's benefit. -conversation for mutual companionship, enjoyment and interaction -sharing of life events and activities -a conversation with the goal of forming a more intimate relationship

The nurse self-discloses only what is necessary for the client's benefit.

A client who gave birth yesterday refuses to eat the food provided by the hospital. She states that she must eat special food brought from home by her family. How would the nurse most appropriately address this situation? -The nurse should plan no action because the client is not exhibiting a health problem. -The nurse should formulate a possible nursing diagnosis and make further observations. -The nurse should formulate an active nursing diagnosis and plan interventions to correct the problem. -The nurse should formulate a collaborative problem and consult with the physician and dietitian.

The nurse should plan no action because the client is not exhibiting a health problem.

A nurse is caring for a client with a nonhealing stage IV pressure ulcer. The nurse observes an area in the wound that is hollow between the outer surface and the wound bed. What is the correct term for this condition? Eschar Tunneling Undermining Dehiscence

Undermining

A preceptor reviews the client outcomes written by a new nurse. Which outcome is the priority for the client with paranoid delusions? -Client will discuss delusions in therapy sessions before discharge. -Within 3 days, client will mingle in the day room without violence. -Client will verbalize side effects of antipsychotic medications within 24 hours. -Within 2 days, client will perform personal hygiene without reminders.

Within 3 days, client will mingle in the day room without violence.

At what point should the nurse perform the first of the three checks of medication administration? -as the nurse reaches for the drug package or container -at the beginning of a shift -when reviewing the client's medication administration record (MAR) -after retrieving the drug from the drawer of a drug cart

as the nurse reaches for the drug package or container

The nurse is preparing to change a client's sterile dressing. Which action by the nurse would increase the risk for infection? -describing each step verbally to the client while performing the dressing change -checking that the sterile dressing packages are intact before opening -opening the gauze pads package before putting on sterile gloves -ensuring that the surface where the sterile field will be set up is dry

describing each step verbally to the client while performing the dressing change

The nurse is caring for a client that has a colonized infection. What assessment data does the nurse anticipate collecting? -fever of 100° F (37.78° C) -no signs or symptoms -alternating periods of nausea and vomiting -reports of feeling well because the infection has resolved

no signs or symptoms

A client with a new colostomy often becomes short and sarcastic when nurses attempt to teach him about the management of his new appliance. The nurse has consequently documented "Noncompliance related hostility" on the client's chart. What mistake has the nurse made when choosing and documenting this nursing diagnosis? -presuming to know the factors contributing to the problem -identifying a problem that cannot be changed -identifying a problem without corroborating evidence in the statement -neglecting to identify potential complications related to the problem

presuming to know the factors contributing to the problem

The nurse is caring for an older adult client admitted to the hospital for a respiratory condition. Types of data that the nurse should review before caring for this client include all EXCEPT which of the following? -consultations -lab reports -medical history -progress notes -salary history -xray reports

salary history