exam 4

The nurse evaluates that there is a need for further teaching on a bowel elimination when the client makes which statement?

" I need to decrease fiber in my diet"

The nurse is encouraging a client to participate in recreational therapy. The client states that.... alone and not bother others. Which statement is an appropriate response from the nurse?

"Can you tell me more about your feelings?

The nurse enters a clients room and finds that the wastebasket is on fire. The nurse quickly assists the client out of the room. Which is the next nursing action?

Activate the fire alarm.

The nurse check the food on a tray delivered for an Orthodox Jewish client and notes the client has received a cheeseburger and potato fries with whole milk as a beverage. Which action should the nurse take?

Call the dietary department and ask for a different meal.

The nurse employed in a long term care facility calls the primary health care provider (PHCP) regarding a new medication prescription because the dose prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due to be administered. Which action should the nurse take next?

Contact the nursing supervisor

The nurse is working with a new nurse employee in a hospice agency. The nurse recognizes the new employee needs further assistance in facilitating effective communication between a client and the family if the new nurse employee performs which action?

The new nurse employee makes decisions for the client and family in order to relieve them of unnecessary demands

The licensed practical nurse (LPN) enters a clients room and finds the client lying on the floor. The LPN calls the registered nurse, who checks the client thoroughly and then assists the client to his bed. The LPN completes an incident report, and the nursing supervisor and primary health care provider (PHCP) are notified of the incident. Which is the next nursing action regarding the incident?

Document a complete entry in the client's record concerning the incident.

The nurse who is caring for a client with kidney failure notes that the client is dyspneic and crackles are heard when listening to breath sounds in the lungs. Which additional sign/symptom should the nurse expect to note in this client?

Increased blood pressure

The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing, When should the nurse inflate the ballon?

Insert the catheter 2.5 cm to 5 cm and inflate the ballon

The nurse is preparing to preform an abdominal examination. Which step would be taken first?

Inspection

The nurse is caring for an older client who is terminally ill. Which signs indicate to the nurse that death may be imminent?

Irregular, noisy breathing and cold, clammy skin

The nurse is instructed to complete a medication reconciliation form on a newly admitted client Why is it important for the nurse to ensure that this process is completed accurately?

It helps to make sure that the health care provider is aware of all of the medications the client is taking and has been taking at home.

The nurse asks a nursing student to describe case management. Which student response indicates a lack of understanding about this concept?

It represents a primary health prevention focus managed by a single case manager

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for a potassium deficit?

The client receiving nasogastric suction

The nurse is caring for a client with kidney failure. The laboratory results reveal a magnesium level of 3.6 mEq/L (1.8mmol/L). Which sign should the nurse expect to note in the client, based on this magnesium level?

Loss of deep tendon reflexes

The nurse is discussing the care needs with an unlicensed assistive personnel (UAP) who is preparing to bathe a client who has mild dementia and requires minimal help with hygiene The nurse Identifies which client need as the highest priority when giving instructions.

Maintain client safety

The nurse is caring for a client with a nasogastric tube that us attached to low suction. The nurse monitors the client closely for which acid based disorder is most likely to occur in this situation?

Metabolic alkalosis

The nurse is attending an agency orientation regarding the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. What does the nurse determine is a characteristic of this type of nursing model?

Nursing personnel are led by an RN leader in providing care to a group of clients

The nurse is preparing to give a bed bath to an immobilized client with TB. The nurse should plan to wear which items while preforming care?

Particulate respirator, gown, and gloves

The nurse is assigned to reinforce instructions to a client and the family about the management of home IV infusion therapy. The nurse begins the process by teaching the client and family principles related to what actions first?

Proper hand-washing technique

The nurse is assisting with collecting data from an African American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which information about the client is of lowest priority during the data collection?

Psychosocial

A client has died and the nurse asks a family member about the funeral program arrangements. The family member refuses to discuss the issue. Which is the appropriate nursing action?

Remain with the family member without discussing funeral arrangements

The nurse observes that a client received pain medication 1 hour ago from another nurse but the client still has severe pain. The nurse has previously observed the same occurrence several times. Based on the nurse practice act, the observing nurse should plan to take which action?

Report the information to nursing supervisor

The nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease (COPD). The nurse should monitor the client for which acid based imbalance?

Respiratory acidosis

The nurse consults with a dietitian regarding dietary preferences of an Asian American client. Which food should the nurse suggest to include in the diet plan?

Rice

A Spanish speaking client arrives at the triage desk in the emergency department and states to the nurse, " No speak english, need interpreter." Which action should the nurse take?

Seek an interpreter from the hospitals interpreter services

A licensed practical nurse is preempting a student assigned to care for a client with chronic pain. Which statement, if made by the student, indicates the need for further teaching regarding pain management?

"I will be sure to cue in to any indicators that the client may be exaggerating their pain."

The nurse is providing directions to the unlicensed assistive personnel (UAP) regarding client hygiene needs, Based on client needs, the nurse instructs the UAP to bathe which client first?

.A confused client who is incontinent of stool and urine

The nurse is checking the apical heart rate of a client with a complaint of angina. The nurse places the stethoscope in which anatomical area. Refer to the figure.

4

A licensed practical nurse is explaining the appropriate methods for measuring an accurate temperature unlicensed assistive personnel (UAP). Which method, if noted by the UAP as being.. indicates the need for further teaching?

Taking an oral temperature for a client with a cough and nasal congestion

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse asks the client to assume a left sims position. The nurse explains that this positioning is preferred because of which reason?

The enema will flow into the bowel easily

The nurse is assisting a client to ambulate when the client states he is feeling faint which action should the nurse take to assist the client now?

The nurse should extend one leg to use to slide the client's body down to the floor.

The nurse obtains a prescription to a restrain client using a belt (safety) restraint and instructs the unlicensed assistive personnel (UAP) to apply the restraint. Which observation, if made by the nurse, indicates unsafe application of the restraint?

The restraint straps are safely secured to the side rails.

As unconscious client, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the clients life. With referred to informed consent for the surgical procedure, which action is best?

Transport the client to the operating departments immediately, as required by the health care provider without obtaining an informed consent

The nurse is planning to feed an older adult client who is at risk for aspiration of food. During the meal how should the nurse position the client?

Up right in a chair

The nurse is giving a client a bed bath and drops the towel on the floor. The nurse should take which action?

Wash hands and go to the linen room to obtain another towel

The nurse is told that. an assigned client is suspected of having methicillin-resistant... MRSA. Which precautions should the nurse institute during the care of the client?

Wear gloves only

The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatermia. Which additional sign/symptom should the nurse expect to note in this client if hyponatremia is present?

postural blood pressure changes

The nurse is caring for a hospitalized older client who has pulled out his IV for the second time. Which intervention should the nurse institute next for this client?

Wrap a light roll of gauze to cover the IV site.

A nurse lawyer provides an education session to the nursing staff regarding client rights with emphasis on invasion of client rights. The nurse lawyer asks a staff nurse to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right?

Taking photographs of a client without consent