Exam 6 Fundamentals

A nurse is providing information about pain control for a client who has acute pain following a subtotal gastric resection. Which of the following client statements indicates an understanding of pain control? A. "I will call for pain medication before the previous dose wears off." B. "I will call for pain medication as my pain starts to increase again." C. "I will wait for you to evaluate my pain before asking for more medication." D. "I will ask for less medication to avoid addiction."

A. "I will call for pain medication before the previous dose wears off."

A nurse is teaching a client about how to use her new hearing aids. Which of the following statements should the nurse identify as an indication that the client needs further instruction? A. "I will clean the hearing aids with alcohol wipes." B. "I will not use hairspray if I am wearing the hearing aids." C. "I will change the batteries once a week." D. "I will expect the hearing aids to whistle when I cup my hand over them."

A. "I will clean the hearing aids with alcohol wipes."

.A nurse is speaking with the mother of a 6-year-old child. Which of the following statements by the mother should concern the nurse? A. "The teacher says my child has to squint to see the board." B. "My child has recently lost both front top teeth." C. "My child often cheats when we play board games." D. "Sometimes my child acts bossy with his friends."

A. "The teacher says my child has to squint to see the board."

A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take? A. Apply the bag for 30 min at a time. B. Reapply the bag 30 min after removing it. C. Allow room for some air inside the bag. D. Place the bag directly on the skin.

A. Apply the bag for 30 min at a time.

A nurse is assessing the respiratory pattern of an older adult client who is receiving end-of-life care. Which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations? A. Breathing ranging from very deep to very shallow with periods of apnea B. Shallow to normal breaths alternating with periods of apnea C. Rapid respirations that are unusually deep and regular D. An inability to breathe without dyspnea unless sitting upright

A. Breathing ranging from very deep to very shallow with periods of apnea

A nurse is educating a client who is experiencing sleep disturbances and desires to decrease caffeine intake. Which of the following beverages should the nurse recommend? A. Lemon-lime soda B. Brewed iced tea C. Diet cola . D. Chocolate milk

A. Lemon-lime soda

A nurse is planning care for a client who is postoperative. Which of the following statements about pain management should the nurse consider when implementing client care? (Select all that apply.) A. Use of analgesics will eventually lead to addiction. B. Each client's expression of pain may be different and individualized. C. Patient-controlled analgesia (PCA) offers a constant level of opioids within therapeutic range. D. Pain level and pain tolerance can be assessed using a scale from 0 to 10. E. The client will express the feeling of pain both verbally and nonverbally.

B. Each client's expression of pain may be different and individualized. C. Patient-controlled analgesia (PCA) offers a constant level of opioids within therapeutic range. D. Pain level and pain tolerance can be assessed using a scale from 0 to 10.

A nurse is caring for a client who is dying of metastatic breast cancer. She has a prescription for an opioid pain medication PRN. The nurse is concerned that administering a dose of pain medication might hasten the client's death. Which of the following ethical principles should the nurse use to support the decision not to administer the medication? A. Utilitarianism B. Nonmaleficence C. Fidelity D. Veracity

B. Nonmaleficence

.A nurse is teaching a client who has a new prescription for ibuprofen to treat hip pain. Which of the following instructions should the nurse include in the teaching? A. Expect ringing in your ears. B. Take the medication with food. C. Store the medication in the refrigerator D. Monitor for weight loss.

B. Take the medication with food.

A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pan? A. Vital sign measurement B. The client's self-report of pain severity C. Visual observation for nonverbal signs of pain D. The nature and invasiveness of the surgical procedure

B. The client's self-report of pain severity

.A nurse is caring for a client who has chemotherapy- induced peripheral neuropathy. The nurse should expect the client to report having experienced which of the following symptoms? A. Extremities that turned blue when exposed to cold B. Tingling feeling in the extremities C. Jerking movements of the extremities D. Spasms of the extremities

B. Tingling feeling in the extremities

.A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first? A. Reposition the client B. Administer the medication. C. Determine the location of the pain. D. Review the effects of the pain medication.

C. Determine the location of the pain.

A nurse is caring for a client who is dying. The nurse should incorporate the principle of nonmaleficence into practice by taking which of the following actions? A. Discussing advance directives with the client and the client's family B. Providing comfort care measures to the client C. Withholding a dose of narcotic pain medication when the client has respiratory depression D. Allowing the client's family unlimited visitation at the time of death

C. Withholding a dose of narcotic pain medication when the client has respiratory depression

A nurse is caring for a client who is 1-day postoperative following a total laryngectomy and has begun a soft diet. The client is not eating well and tells the nurse that the hospital food has no taste. Which of the following responses is appropriate for the nurse to make? A. "You should ask your family to bring you some food from home." B. "Clients frequently complain about the taste of hospital food." C. "I would be happy to get you food that you prefer to eat." D. "Because of your surgery, you have an altered ability to smell and taste."

D. "Because of your surgery, you have an altered ability to smell and taste."

A nurse is instructing a young adult client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further teaching? A. "I don't take naps throughout the day." B. "I go to bed and get up routinely at the same time each day." C. "I have a small snack and take a bath before going to bed each day." D. "I watch television until I fall asleep at night."

D. "I watch television until I fall asleep at night."

a nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching? A. it might help if I tried sleeping on my back B. Ill sleep better if I take a sleeping pill at night C. Ill get a humidifier to run at my bedside at night D. If I could lose about 50 lbs, I might stop having so many apneic episodes

D. If I could lose about 50 lbs, I might stop having so many apneic episodes

A nurse is preparing to administer meperidine 35 mg IM to a client every 6 hr PRN for pain. Available is meperidine injection 75 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

0.5 mL

A nurse in the emergency department is preparing to administer naloxone 0.4 mg IV bolus to a client who has opioid-induced respiratory depression. Available is naloxone injection 0.2 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

2 mL

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort? A) Obtain a pair of slipper socks for the client B) Rub the clients feet briskly for several minutes C) Increase the client's oral fluid intake D) Place a moist heating pad under the client's feet

A) Obtain a pair of slipper socks for the client

A nurse is caring for a client who is postoperative following abdominal surgery and reports incisional pain. The surgeon has prescribed morphine 4 mg IV bolus every 6 hr as needed. Before administering this medication, the nurse should complete which priority assessment? A. Blood pressure B. Apical heart rate C. Respiratory rate D. Temperature

C. Respiratory rate

.A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take? A. Insert a nasogastric tube B. Administer an antiemetic. C. Encourage use of the incentive spirometer. D. Auscultate bowel sounds

D. Auscultate bowel sounds

.A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse? A. Speak using his usual tone of voice. B. Stand directly in front of the client. C. Rephrase statements the client does not hear D. Determine if the client uses hearing aids.

D. Determine if the client uses hearing aids.

A nurse is caring for a client who reports difficulty sleeping while in the hospital. Which of the following actions taken by the assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene? A. Closes the door to the client's room B. Measures the client's vital signs routinely C. Asks a group of nurses in the hall to speak quietly D. Flushes the client's toilet after emptying the urinary catheter's drainage bag

D. Flushes the client's toilet after emptying the urinary catheter's drainage bag

A hospice nurse is caring for a client who has terminal cancer and takes PO morphine for pain relief. The client reports that he had to increase the dose of morphine this week to obtain pain relief. Which of the following scenarios should the nurse document as the explanation for this situation? A. The client not been taking the medication properly. B. The client is experiencing episodes of confusion. C. The client has become addicted to the medication. D. The client developed a tolerance to the medication.

D. The client developed a tolerance to the medication.

A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level? A. pulse and blood pressure findings B. behavioral indicators and effect C. scheduled treatments and client illness D. a self-report pain rating scale

D. a self-report pain rating scale