Final Exam 222
Which statement provides evidence that an older adult who is prone to constipation is in need of further teaching? A. "I need to drink one and a half to 2 quarts of liquid each day." B. "I need to take a laxative such as milk of magnesia or if I don't have a BM every day." C. "If my bowel pattern changes on its own, I should call you." D. "Eating my meals at regular times is likely to result in regular bowel movements."
"I need to take a laxative such as milk of magnesia or if I don't have a BM every day."
Which statement indicates a need for further teaching of a home care client with a long term indwelling catheter? A. "I will keep the collecting bag below the level of the bladder at all times." B. "Intake of cranberry juice may help decrease the risk of infection." C. "Soaking in a warm tub bath may ease the irritation associated with the catheter." D. "I should use clean tech. when emptying the collecting bag."
"Soaking in a warm tub bath may ease the irritation associated with the catheter."
The charge nurse asks the nursing assistive personnel (NAP) to give a bag bath to a patient with end-stage chronic obstructive pulmonary disease. How should the NAP proceed? A. Bathe the patient's entire body using 8 to 10 washcloths. B. Assist the patient to a chair and provide bathing supplies. C. Saturate a towel and blanket in a plastic bag, and then bathe the patient. D. Assist the patient to the bathtub and provide a bath chair.
. Bathe the patient's entire body using 8 to 10 washcloths.
The clinical instructor asks her students the rationale for handwashing. The students are correct if they answered that handwashing is expected to remove: A. Transient flora from the skin B. Resident flora from the skin C. All microorganisms from the skin D. Media for bacterial growth
. Transient flora from the skin
1800 ml is equal to how many liters? A. 1.8 B. 18000 C. 180 D. 2800
1.8
The nurse in charge measures a patient's temperature at 102 degrees F. what is the equivalent Centigrade temperature? A. 39 degrees C B. 47 degrees C C. 38.9 degrees C D. 40.1 degrees C
38.9 degrees C
Which nursing diagnosis is/are most applicable to a client with fecal incontinence? Select all that apply. A. Bowel incontinence B. Risk for deficient fluid volume C. Disturbed body image D. Social isolation E. Risk for impaired skin integrity
A,C,D,E
A client with a stage 2 pressure ulcer has methicillin-resistant Staphylococcus aureus (MRSA) cultured from the wound. Contact precautions are initiated. Which rule must be observed to follow contact precautions? A. A clean gown and gloves must be worn when in contact with the client. B. Everyone who enters the room must wear a N-95 respirator mask. C. All linen and trash must be marked as contaminated and send to biohazard waste. D. Place the client in a room with a client with an upper respiratory infection.
A. A clean gown and gloves must be worn when in contact with the client.
The nurse is recording assessment data. She writes, "The patient seems worried about his surgery. Other than that, he had a good night." Which errors did the nurse make? Select all that apply. A. Used a vague generality. B. Did not use the patient's exact words. C. Used a "waffle" word (e.g., appears). D. Recorded an inference rather than a cue. E. Did not record the patient's vital signs.
A. Used a vague generality. C. Used a "waffle" word (e.g., appears). D. Recorded an inference rather than a cue. E. Did not record the patient's vital signs.
To evaluate a patient for hypoxia, the physician is most likely to order which laboratory test? A. Red blood cell count B. Sputum culture C. Total hemoglobin D. Arterial blood gas (ABG) analysis
ABG
Which intervention is an example of primary prevention? A. Administering digoxin (Lanoxicaps) to a patient with heart failure. B. Administering measles, mumps, and rubella immunization to an infant. C. Obtaining a Papanicolaou smear to screen for cervical cancer. D. Using occupational therapy to help a patient cope with arthritis.
Administering measles, mumps, and rubella immunization to an infant.
A client requires protective isolation. Which client can be safely paired with this client in a client-care assignment? One: A. Admitted with unstable diabetes mellitus. B. Who underwent surgical repair of a perforated bowel. C. With a stage 3 sacral pressure ulcer. D. Admitted with a urinary tract infection.
Admitted with unstable diabetes mellitus.
A client with a new stoma who has not had a bowel movement since surgery last week reports feeling nauseous. What is the appropriate nursing action? A. Prepare to irrigate the colostomy. B. After assessing the stoma and surrounding skin, notify the surgeon. C. Assess bowel sounds and administer antiemetic. D. Administer a bulk forming laxative, and encourage increased fluids and exercise.
After assessing the stoma and surrounding skin, notify the surgeon.
When administering drug therapy to a male geriatric patient, the nurse must stay especially alert for adverse effects. Which factor makes geriatric patients have adverse drug effects? A. Faster drug clearance B. Aging-related physiological changes C. Increased amount of neurons D. Enhanced blood flow to the GI tract
Aging-related physiological changes
A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive highest priority at this time? A. Impaired gas exchanges related to increased blood flow. B. Fluid volume excess related to peripheral vascular disease. C. Risk for injury related to edema. D. Altered peripheral tissue perfusion related to venous congestion.
Altered peripheral tissue perfusion related to venous congestion.
The nurse inspects a client's pupil size and determines that it's 2 mm in the left eye and 3 mm in the right eye. Unequal pupils are known as: A. Anisocoria B. Ataxia C. Cataract D. Diplopia
Anisocoria
The nurse is working on a unit that uses nursing assessment flow sheets. Which statement best describes this form of charting? Nursing assessment flow sheets: A. Are comprehensive charting forms that integrate assessments and nursing actions. B. Contain only graphic information, such as I&O, vital signs, and medication administration. C. Are used to record routine aspects of care; they do not contain assessment data. D. Contain vital data collected upon admission, which can be compared with newly collected data.
Are comprehensive charting forms that integrate assessments and nursing actions.
Critical thinking and the nursing process have which of the following in common?
Are important to use in nursing practice.
A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this client would be to: A. Assess the client's airway. B. Provide pain relief. C. Encourage deep breathing and coughing. D. Splint the chest wall with a pillow.
Assess the airway
A walk-in client enters the clinic with a chief complaint of abdominal pain and diarrhea. The nurse takes the client's vital sign hereafter. What phrase of the nursing process is being implemented here by the nurse? A. Assessment B. Diagnosis C. Planning D. Implementation
Assessment
Arrange the steps of the nursing process in the sequence in which they generally occur. Planning interventions Evaluation Diagnosis Assessment Planning outcomes
Assessment Diagnosis Planning outcomes Planning interventions Evaluation
A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client's body temperature? A. Oral B. Axillary C. Arterial line D. Rectal
Axillary
The nurse is preparing to take vital signs in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the best method used to assess the client's temperature? A. Oral B. Axillary C. Radial D. Heat sensitive tape
Axillary
A female patient is receiving furosemide (Lasix), 40 mg P.O. b.i.D. in the plan of care, the nurse should emphasize teaching the patient about the importance of consuming: A. Fresh, green vegetables B. Bananas and oranges C. Lean red meat D. Creamed corn
Bananas and organes
Which of the following symptoms is the best indicator of imminent death? A. A weak, slow pulse B. Increased muscle tone C. Fixed, dilated pupils D. Slow, shallow respirations
C. Fixed, dilated pupils
A terminally ill patient usually experiences all of the following feelings during the anger stage except: A. Rage B. Envy C. Numbness D. Resentment
C. Numbness
Nurses and other healthcare providers often have difficulty helping a terminally ill patient through the necessary stages leading to acceptance of death. Which of the following strategies is most helpful to the nurse in achieving this goal? A. Taking psychology courses related to gerontology. B. Reading books and other literature on the subject of thanatology. C. Reflecting on the significance of death. D. Reviewing varying cultural beliefs and practices related to death.
C. Reflecting on the significance of death.
Which pulse should the nurse palpate during rapid assessment of an unconscious male adult? A. Radial B. Brachial C. Femoral D. Carotid
Carotid
A nurse caring for a patient with an infectious disease who requires isolation should refers to guidelines published by the:
Centers for Disease Control (CDC)
Which action represents the appropriate nursing management of a client wearing a condom catheter? A. Ensure that the tip of the penis fits snugly against the end of the condom. B. Check the penis for adequate circulation 30 min after applying. C. Change the condom every 8 hours. D. Tape the collecting tube to the lower abdomen.
Check the penis for adequate circulation 30 min after applying.
A client who has an indwelling catheter reports the need to urinate. Which of the following interventions should the nurse perform? A. Check to see whether the catheter is patent. B. Reassure the client that it is not possible for her to urinate. C. Re-catheterize the bladder with a larger gauge catheter. D. Collect a urine specimen for analysis.
Check to see whether the catheter is patent.
Which action by the nurse in charge is essential when cleaning the area around a Jackson-Pratt wound drain? A. Cleaning from the center outward in a circular motion. B. Removing the drain before cleaning the skin. C. Cleaning briskly around the site with alcohol. D. Wearing sterile gloves and a mask.
Cleaning from the center outward in a circular motion.
It is described as a collection of people who share some attributes of their lives. A. Family B. Illness C. Community D. Nursing
Community
A male patient has a soft wrist-safety device. Which assessment finding should the nurse consider abnormal? A. A palpable radial pulse B. A palpable ulnar pulse C. Cool, pale fingers D. Pink nail beds
Cool, pale fingers
Which focus is the nurse most likely to teach for a client with a flaccid bladder? A. Habit training: attempt voiding at specific time periods. B. Bladder training: delay voiding according to a pre-schedule timetable. C. Crede's maneuver: apply gentle manual pressure to the lower abdomen. D. Kegel exercises: contract the pelvic muscles.
Crede's maneuver: apply gentle manual pressure to the lower abdomen.
A client with chronic pulmonary disease has a bluish tinge around the lips. The nurse charts which term to most accurately describe the client's condition? A. Hypoxia B. Hypoxemia C. Dyspnea D. Cyanosis
Cyanosis
A female patient who speaks a little English has emergency gallbladder surgery, during discharge preparation, which nursing action would best help this patient understand wound care instruction? A. Asking frequently if the patient understands the instruction. B. Asking an interpreter to replay the instructions to the patient. C. Writing out the instructions and having a family member read them to the patient. D. Demonstrating the procedure and having the patient return the demonstration.
D
Which of the following is the nurse's legal responsibility when applying restraints? A. Document the patient's behavior. B. Document the type of restraint used. C. Obtain a written order from the physician except in an emergency, when the patient must be protected from injury to himself or others. D. All of the above.
D. All of the above.
Restraints can be used for all of the following purposes except to: A. Prevent a confused patient from removing tubes, such as feeding tubes, I.V. lines, and urinary catheters. B. Prevent a patient from falling out of bed or a chair. C. Discourage a patient from attempting to ambulate alone when he requires assistance for his safety. D. Prevent a patient from becoming confused or disoriented.
D. Prevent a patient from becoming confused or disoriented.
A newly hired at Nurseslabs Medical Center is assigned to the OR Department. Which action demonstrates a break in sterile technique? A. Remaining 1 foot away from non sterile areas. B. Placing sterile items on the sterile field. C. Avoiding the border of the sterile drape. D. Reaching 1 foot over the sterile field.
D. Reaching 1 foot over the sterile field.
How should the nurse modify the examination for a 7-year-old child? A. Ask the parents to leave the room before the examination. B. Demonstrate equipment before using it. C. Allow the child to help with the examination. D. Perform invasive procedures (e.g., otoscopic) last.
Demonstrate
Kubler-Ross's five successive stages of death and dying are:
Denial, anger, bargaining, depression acceptance
In which step of the nursing process does the nurse analyze data and identify client problems? A. Assessment B. Diagnosis C. Planning outcomes D. Evaluation
Diagonosis
A provider prescribes a 24-hour urine collection for a client. Which of the following actions should the nurse take? A. Discard the first voiding. B. Keep all voidings in a container at room temperature. C. Ask the client to urinate and pour the urine into a specimen container. D. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container.
Discard the first voiding.
Before administering the evening dose of a prescribed medication, the nurse on the evening shift finds an unlabeled, filled syringe in the patient's medication drawer. What should the nurse in charge do?
Discard the syringe to avoid a medication error.
One aspect of implementation related to drug therapy is: A. Developing a content outline. B. Documenting drugs given. C. Establishing outcome criteria. D. Setting realistic client goals.
Documenting
A nurse discourages a patient from straining excessively when attempting to have a bowel movement. What physiological response primarily may be prevented by avoiding straining on defecation? A. Incontinence B. Dysrhythmias C. Fecal impaction D. Rectal hemorrhoids
Dysrthythmias
A female patient is being discharged after cataract surgery. After providing medication teaching, the nurse asks the patient to repeat the instructions. The nurse is performing which professional role?
Educator
Which nursing action is essential when providing continuous enteral feeding? A. Elevating the head of the bed. B. Positioning the patient on the left side. C. Warming the formula before administering it. D. Hanging a full day's worth of formula at one time.
Elevating the head of the bed
Using Abraham Maslow's hierarchy of human needs, a nurse assigns highest priority to which client need? A. Security B. Elimination C. Safety D. Belonging
Elimination
The most important nursing intervention to correct skin dryness is:
Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas.
In which phase of the nursing process does the nurse decide whether her actions have successfully treated the client's health problem? A. Assessment B. Diagnosis C. Planning outcomes D. Evaluation
Evaluation
Nurse Nikki is revising a client's care plan. During which step of the nursing process does such revision take place? A. Assessment B. Planning C. Implementation D. Evaluation
Evaluation
Which of the following actions should the nurse take to use wide base support when assisting a client to get up in a chair? A. Bend at the waist and place arms under the client's arms and lift. B. Face the client, bend knees, and place hands-on client's forearm and lift. C. Spread his or her feet apart. D. Tighten his or her pelvic muscles.
Face the client, bend knees, and place hands-on client's forearm and lift.
A patient is admitted with shortness of breath, so the nurse immediately listens to his breath sounds. Which type of assessment is the nurse performing? A. Ongoing assessment B. Comprehensive physical assessment C. Focused physical assessment D. Psychosocial assessment
Focused physical assessment
Which of the following planes divides the body longitudinally into anterior and posterior regions? A. Frontal plane B. Sagittal plane C. Midsagittal plane D. Transverse plane
Frontal
The charge nurse on the medical-surgical floor assigns vital signs to the nursing assistive personnel (NAP) and medication administration to the licensed vocational nurse (LVN). Which nursing model of care is this floor following? A. Team nursing B. Case method nursing C. Functional nursing D. Primary nursing
Functional nursing
The best way to decrease the risk of transferring pathogens to a patient when removing contaminated gloves is to:
Gently pull just below the cuff and invert the gloves when removing them.
A nurse must measure the intake and output (I&O) for a patient who has a urinary retention catheter. Which equipment is most appropriate to use to accurately measure urine output from a urinary retention catheter? A. Urinal B. Graduate C. Large syringe D. Urine collection bag
Graduate
A nurse determines that a fracture bedpan should be used for the patient who: A. Has a spinal cord injury B. Is on bedrest C. Has dementia D. Is obese
Has a spinal cord injury
Which is the correct procedure for collecting a sputum specimen for culture and sensitivity testing?
Have the patient expectorate the sputum into a sterile container.
Nursing interventions that can help the patient to relax and sleep restfully include all of the following except: A. Have the patient take a 30- to 60-minute nap in the afternoon. B. Turn on the television in the patient's room. C. Provide quiet music and interesting reading material. D. Massage the patient's back with long strokes.
Have the patient take a 30- to 60-minute nap in the afternoon.
The nurse in charge is caring for an Italian client. He's complaining of pain, but he falls asleep right after his complaint and before the nurse can assess his pain. The nurse concludes that: A. He may have a low threshold for pain. B. He was faking pain. C. Someone else gave him medication. D. The pain went away.
He may have a low threshold for pain
The nurse in charge is transferring a patient from the bed to a chair. Which action does the nurse take during this patient transfer? A. Position the head of the bed flat. B. Helps the patient dangle the legs. C. Stands behind the patient. D. Place the chair facing away from the bed.
Helps the patient dangle the legs.
A patient is catheterized with a #16 indwelling urinary (Foley) catheter to determine if:
His 24-hour output is adequate.
Which statement by a patient with an ileostomy alerts the nurse to the need for further education? A. "I don't expect to have much of a problem with fecal odor." B. "I will have to take special precaution to protect my skin around the stoma." C. "I'm going to have to irrigate my stoma so I have a bowel movement every morning." D. "I should avoid gas forming foods like beans to limit funny noises from the stoma."
I'm going to have to irrigate my stoma so I have a bowel movement every morning."
What is the most basic reason that self-knowledge is important for nurses? Because it helps the nurse to: A. Identify personal biases that may affect his thinking and actions. B. Identify the most effective interventions for a patient. C. Communicate more efficiently with colleagues, patients, and families. D. Learn and remember new procedures and techniques.
Identify personal biases that may affect his thinking and actions.
The ability of the body to defend itself against scientific invading agent such as bacteria, toxin, viruses, and foreign body: A. Hormones B. Secretion C. Immunity D. Glands
Immunity
A male client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal? A. Inadequate vitamin D intake. B. Inadequate protein intake. C. Inadequate massaging of the affected area. D. Low calcium level.
Inadequate protein intake
When bathing a patient's extremities, the nurse should use long, firm strokes from the distal to the proximal areas. This technique:
Increases venous blood return.
How are critical thinking skills and critical thinking attitudes similar?
Influences on the nurse's problem solving and decision making.
The nurse in charge is assessing a patient's abdomen. Which examination technique should the nurse use first? A. Auscultation B. Inspection C. Percussion D. Palpation
Inspection
Hormones secreted by Islets of Langerhans A. Progesterone B. Testosterone C. Insulin D. Hemoglobin
Insulin
A client exhibits all of the following during a physical assessment. Which of these is considered a primary defense against infection? A. Fever B. Intact skin C. Inflammation D. Lethargy
Intact skin
Patient Z asks Nurse Toni why an electronic health record (EHR) system is being used. Which response by the nurse indicates an understanding of the rationale for an EHR system? A. It includes organizational reports of unusual occurrences that are not part of the client's record. B. This type of system consists of combined documentation and daily care plans. C. It improves interdisciplinary collaboration that improves efficiency in procedures. D. This type of system tracks medication administration and usage over 24 hours.
It improves interdisciplinary collaboration that improves efficiency in procedures.
A patient with the diagnosis of diverticulosis is advised to eat a diet high in fiber. What should the nurse recommend that the patient eat to best increase the bulk and fecal material? A. Whole wheat bread B. White rice C. Pasta D. Kale
Kale
A client is hospitalized for the first time, which of the following actions ensure the safety of the client? A. Keep unnecessary furniture out of the way. B. Keep the lights on at all times. C. Keep side rails up at all times. D. Keep all equipment out of view.
Keep the side rails up at all times
The catheter slips into the vagina during a straight catheterization of a female client. The nurse does which action? A. Leaves the catheter in place and gets a new sterile catheter. B. Leaves the catheter in place and asks another nurse to attempt the procedure. C. Removes the catheter and redirects it to the urinary meatus. D. Removes the catheter, wipes it with a sterile gauze, and redirects it to the urinary meatus.
Leaves the catheter in place and gets a new sterile catheter.
A female patient exhibits signs of heightened anxiety. Which response by the nurse is most likely to reduce the patient's anxiety? A. "Everything will be fine. Don't worry." B. "Read this manual and then ask me any questions you may have." C. "Why don't you listen to the radio?" D. "Let's talk about what's bothering you."
Let's talk about what's bothering you."
A client is scheduled for a colonoscopy. The nurse will provide information to the client about which type of enema? A. Oil retention B. Return flow C. High large volume D. Low, small volume
Low small volume
While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following is the appropriate intervention? A. Have a client hold his breath briefly. B. Discontinue the fluid installation. C. Remind the client that cramping is common at this time. D. Lower the enema fluid container.
Lower the enema fluid container
A practitioner orders a return flow enema (Harris flush drip) for an adult patient with flatulence. When preparing to administer this enema the nurse compares the steps of a return flow enema with cleansing enemas. What should the nurse do that is unique to a return flow enema? A. Lubricate the last 2 inches of the rectal tube. B. Insert the rectal tube about 4 inches into the anus. C. Raise the solution container about 12 inches above the anus. D. Lower the solution container after instilling about 150 mL of solution.
Lower the solution
Which of the following is included in Orem's theory? A. Maintenance of a sufficient intake of air. B. Self perception. C. Love and belongingness. D. Physiologic needs.
Maintenance of a sufficient intake of air
At the end of the shift, the nurse realizes that she forgot to document a dressing change that she performed for a patient. Which action should the nurse take? A. Complete an occurrence report before leaving. B. Do nothing; the next nurse will document it was done. C. Write the note of the dressing change into an earlier note. D. Make a late entry as an addition to the narrative notes.
Make a late entry as an addition to the narrative notes.
A staff nurse who is promoted to assistant nurse manager may feel uncomfortable initially when supervising her former peers. She can best decrease this discomfort by:
Making changes after evaluating the situation and having discussions with the staff.
The nurse wishes to identify nursing diagnoses for a patient. She can best do this by using a data collection form organized according to: Select all that apply. A. A body systems model B. A head-to-toe framework C. Maslow's hierarchy of needs D. Gordon's functional health patterns E. Adaptation Model of Nursing
Maslow's hierarchy of needs Gordon's functional health patterns
While examining a client's leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for the nurse in charge to apply? A. Dry sterile dressing B. Sterile petroleum gauze C. Moist, sterile saline gauze D. Povidone-iodine-soaked gauze
Moist, sterile saline gauze
The nurse in charge identifies a patient's responses to actual or potential health problems during which step of the nursing process? A. Assessment B. Nursing diagnosis C. Planning D. Evaluation
Nursing diagnosis
It is best described as a systematic, rational method of planning and providing nursing care for individual, families, group, and community A. Assessment B. Nursing Process C. Diagnosis D. Implementation
Nursing process
A patient has just received 30 mg of codeine by mouth for pain. Five minutes later he vomits. What should the nurse do first?
Observe the emesis
To institute appropriate isolation precautions, the nurse must first know the:
Organism's mode of transmission
Which document addresses the client's right to information, informed consent, and treatment refusal? A. Standard of Nursing Practice B. Patient's Bill of Rights C. Nurse Practice Act D. Code for Nurses
Patient's bill of rights
Which of the following incidents requires the nurse to complete an occurrence report? A. Medication given 30 minutes after scheduled dose time. B. Patient's dentures lost after transfer. C. Worn electrical cord discovered on an IV infusion pump. D. Prescription without the route of administration.
Patient's dentures lost after transfer.
The nurse inspects a client's back and notices small hemorrhagic spots. The nurse documents that the client has: A. Extravasation B. Osteomalacia C. Petechiae D. Uremia
Petechiae
A nurse is caring for a debilitated female patient with nocturia. Which nursing intervention is the priority when planning to meet this patient's needs? A. Encouraging the use of bladder training exercises. B. Providing assistance with toileting every four hours. C. Positioning a bedside commode near the bed. D. Teaching the avoidance of fluid after 5 PM.
Positioning a bedside commode near the bed.
Which of the following aspects of nursing is essential to defining it as both a profession and a discipline? A. Established standards of care B. Professional organizations C. Practice supported by scientific research D. Activities determined by a scope of practice
Practice supported by scientific research
An autoclave is used to sterilize hospital supplies because:
Pressurized steam penetrates the supplies better.
An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of health promotion? A. Primary prevention B. Secondary prevention C. Tertiary prevention D. Passive prevention
Primary
A male client blood test results are as follows: white blood cell (WBC) count, 100ul; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 40%. Which goal would be most important for this client? A. Promote fluid balance B. Prevent infection C. Promote rest D. Prevent injury
Promote infection
A nurse has identified that the patient has overflow incontinence. What is a major factor that contributes to this clinical manifestation? A. Coughing B. Mobility deficits C. Prostate enlargement D. Urinary tract infection
Prostate enlargement
Which intervention should the nurse in charge try first for a client that exhibits signs of sleep disturbance? A. Administer sleeping medication before bedtime. B. Ask the client each morning to describe the quantity of sleep during the previous night. C. Teach the client relaxation techniques, such as guided imagery, medication, and progressive muscle relaxation. D. Provide the client with normal sleep aids, such as pillows, back rubs, and snacks.
Provide the client with normal sleep aids, such as pillows, back rubs, and snacks.
Vivid dreaming occurs in which stage of sleep?
Rapid eye movement (REM) stage
A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor would the nurse recognize as most important? A. A history of increased aspirin use. B. Recent pelvic surgery. C. An active daily walking program. D. A history of diabetes.
Recent pelvic sx
A female patient undergoes a total abdominal hysterectomy. When assessing the patient 10 hours later, the nurse identifies which finding as an early sign of shock? A. Restlessness B. Pale, warm, dry skin C. Heart rate of 110 beats/minute D. Urine output of 30 ml/hour
Restlessness
The nurse assesses a client's abdomen several days after abdominal surgery. It is firm, distended, and painful to palpate. The client reports feeling "bloated" . The nurse consults with the surgeon, who orders an enema. The nurse prepares to give what kind of enema? A. Soapsuds B. Retention C. Return flow D. Oil retention
Return flow
A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client? A. Acute pain related to surgery. B. Deficient fluid volume related to blood and fluid loss from surgery. C. Impaired physical mobility related to surgery. D. Risk for aspiration related to anesthesia.
Risk for aspiration related to anesthesia.
Which action by the nurse represents proper nasopharyngeal/nasotracheal suctioning technique? A. Lubricate the suction catheter with petroleum jelly before and between insertion. B. Apply suction intermittently while inserting the suction catheter. C. Rotate the catheter while applying suction. D. Hyper oxygenate with 100% oxygen for 30 minutes before and after suctioning.
Rotate the catheter while applying suction.
The nurse is preparing to admit a patient from the emergency department. The transferring nurse reports that the patient with chronic lung disease has a 30+ year history of tobacco use. The nurse used to smoke a pack of cigarettes a day at one time and worked very hard to quit smoking. She immediately thinks to herself, "I know I tend to feel negative about people who use tobacco, especially when they have a serious lung condition; I figure if I can stop smoking, they should be able to. I must remember how physically and psychologically difficult that is, and be very careful not to let it be judgmental of this patient." This best illustrates: A. Theoretical knowledge B. Self-knowledge C. Using reliable resources D. Use of the nursing process
Self-knowledge
Which of the following is most likely to validate that a client is experiencing intestinal bleeding? A. Large quantities of fat mixed with pale yellow liquid stool B. Brown, formed stool C. Semi soft tar colored stools D. Narrow, pencil shaped stool
Semi soft tar colored stool
The nurse must examine a patient who is weak and unable to sit unaided or to get out of bed. How should she position the patient to begin and perform most of the physical examination? A. Dorsal recumbent B. Semi-Fowler's C. Lithotomy D. Sims'
Semi-Fowlers
Nurse Clarisse is teaching a patient about a newly prescribed drug. What could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications?
Sensory deficits
For a morbidly obese patient, which intervention should the nurse choose to counteract the pressure created by the skin folds? A. Cover the mattress with a sheepskin. B. Keep the linens wrinkle free. C. Separate the skin folds with towels. D. Apply petrolatum barrier creams.
Separate the skin folds with towels
The nurse is orienting a new nurse to the unit and reviews source-oriented charting. Which statement by the nurse best describes source-oriented charting? Source-oriented charting: A. Separates the health record according to discipline. B. Organizes documentation around the patient's problems. C. Highlights the patient's concerns, problems, and strengths. D. Is designed to streamline documentation.
Separates the health record according to discipline.
A female patient with a terminal illness is in denial. Indicators of denial include: A. Shock dismay B. Numbness C. Stoicism D. Preparatory grief
Shock
A client who is unconscious needs frequent mouth care. When performing mouth care, the best position of a client is: A. Fowler's position B. Side-lying C. Supine D. Trendelenburg
Side lying
Following a tonsillectomy, a female client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. Which position would be most therapeutic for this client? A. Semi-Fowler's B. Supine C. High-Fowler's D. Side-lying
Side-lying
The nurse is assessing a patient admitted to the hospital with rectal bleeding. The patient had a hip replacement 2 weeks ago. Which position should the nurse avoid when examining this patient's rectal area? A. Sims' B. Supine C. Dorsal recumbent D. Semi-Fowler's
Sims
The nurse is assessing vital signs for a patient just admitted to the hospital. Ideally, and if there are no contraindications, how should the nurse position the patient for this portion of the admission assessment? A. Sitting upright. B. Lying flat on the back with knees flexed. C. Lying flat on the back with arms and legs fully extended. D. Side-lying with the knees flexed.
Sitting upright
Which of the following is an example of appropriate behavior when conducting a client interview? A. Recording all the information on the agency-approved form during the interview. B. Asking the client, "Why did you think it was necessary to seek health care at this time?" C. Using precise medical terminology when asking the client questions. D. Sitting, facing the client in a chair at the client's bedside, using active listening.
Sitting, facing the client in a chair at the client's bedside, using active listening.
Paul Jake suffered a stroke and has difficulty swallowing. Which healthcare team member should be consulted to assess the patient's risk for aspiration? A. Respiratory therapist B. Occupational therapist C. Dentist D. Speech therapist
Speech
A nurse assigned to care for a postoperative male client who has diabetes mellitus. During the assessment interview, the client reports that he's impotent and says that he's concerned about its effect on his marriage. In planning this client's care, the most appropriate intervention would be to: A. Encourage the client to ask questions about personal sexuality. B. Provide time for privacy. C. Provide support for the spouse or significant other. D. Suggest referral to a sex counselor or other appropriate professional.
Suggest referral to a sex counselor or other appropriate professional.
Which of the following is the nurse's role in health promotion? A. Health risk appraisal B. Teach client to be effective health consumer C. Worksite wellness D. None of the above
Teach client to be effective health consumer
Nurse Trixie is preparing to perform tracheostomy care. Prior to the beginning of the procedure, the nurse performs which action? A. Tells the client to raise two fingers to indicate pain or distress. B. Changes twill tape holding the tracheostomy and place. C. Cleans the incision site. D. Check the tightness of the ties and knot.
Tells the client to raise two fingers to indicate pain or distress.
Which organization's standards require that all patients be assessed specifically for pain? A. American Nurses Association (ANA) B. State nurse practice acts C. National Council of State Boards of Nursing (NCSBN) D. The Joint Commission
The Joint Commision
The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following? A. The bladder distends and its capacity increases. B. Older adults ignore the need to void. C. Urine becomes more concentrated. D. The amount of urine retained after voiding increases.
The amount of urine retained after voiding increases.
Which of the following is an example of data that should be validated? A. The urinalysis report indicates there are white blood cells in the urine. B. The client states she feels feverish; you measure the oral temperature at 98°F. C. The client has clear breath sounds; you count a respiratory rate of 18. D. The chest x-ray report indicates the client has pneumonia in the right lower lobe.
The client states she feels feverish; you measure the oral temperature at 98°F.
Which goal is the most appropriate for clients with diarrhea related to ingestion of an antibiotic for an upper respiratory infection? A. The client will wear a medical alert bracelet for antibiotic allergy. B. The client will return to his or her previous fecal elimination pattern. C. The client verbalizes the need to take an antidiarrheal medication PRN. D. The client will increase intake of insoluble fiber such as grains, rice, and cereals.
The client will return to his or her previous fecal elimination pattern.
Which human element considered by the nurse in charge during assessment can affect drug administration? A. The patient's ability to recover B. The patient's occupational hazards C. The patient's socioeconomic status D. The patient's cognitive abilities
The patient's cognitive abilities
A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should the nurse include when explaining the procedure to the client? A. Eating more protein is optimal prior to testing. B. One stool specimen is sufficient for testing. C. A red color changes indicates a positive test. D. The specimen cannot be contaminated with urine.
The specimen cannot be contaminated with urine.
the nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy? A. The stoma extends 1/2 inch above the abdomen. B. The skin under the appliance looks red briefly after removing the appliance. C. The stoma color is a deep red purple. D. An ascending colostomy just delivers liquid feces.
The stoma color is a deep red purple.
When examining a patient with abdominal pain the nurse in charge should assess:
The symptomatic quadrant last
The natural sedative in meat and milk products (especially warm milk) that can help induce sleep is:
Tryptophan
A patient's urine is cloudy, is amber, and has an unpleasant odor. What problem may this information indicate that requires the nurse to make a focused assessment? A. Urinary retention B. Urinary tract infection C. Ketone bodies in the urine D. High urinary calcium level
UTI
A newly hired charge nurse assesses the staff nurses as competent individually but ineffective and unproductive as a team. In addressing her concern, the charge nurse should understand that the usual reason for such a situation is: A. Unhappiness about the charge in leadership. B. Unexpected feelings and emotions among the staff. C. Fatigue from overwork and understaffing. D. Failure to incorporate staff in decision making.
Unexpected feelings and emotions among the staff.
During shift report, the nurse learns that an older female client is unable to maintain continence after she senses the urge to void and becomes incontinent on the way to the bathroom. Which nursing diagnosis is most appropriate? A. Stress urinary incontinence B. Reflex urinary incontinence C. Functional urinary incontinence D. Urge urinary incontinence
Urge urinary incontinence
A practitioner uses a urine specimen for culture and sensitivity via a straight catheter for a patient. What should the nurse do when collecting this urine specimen? A. Use a sterile specimen container. B. Collect urine from the catheter port. C. Inflate the balloon with 10 mL of sterile water. D. Have the patient void before collecting the specimen.
Use a sterile specimen container.
A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following are appropriate steps for the nurse to take? Select all that apply. A. Warm the enema solution prior to installation. B. Position the client on the left side with the right leg flexed forward. C. Lubricate the rectal tube or nozzle. D. Slowly insert the rectal tube about 2 inches. E. Hang the enema container 24 inches above the clients anus.
a,b,c
A female client has a urinary tract infection. Which teaching points by the nurse should be helpful to the client? Select all that apply. A. Limit fluids to avoid the burning sensation on urination. B. Review symptoms of UTI with the client. C. Wipe the perineal area from back to front. D. Wear cotton underclothes. E. Take baths rather than showers.
b, d
A nurse is caring for a client who has diarrhea for the past four days. When assessing a client, the nurse should expect which of the following findings? Select all that apply. A. Bradycardia B. Hypotension C. Fever D. Poor skin turgor
b, d
Which of the following behaviors indicates that the client on a bladder training program has met the expected outcomes? Select all that apply. A. Voids each time there is an urge. B. Practices slow, deep breathing until the urge decreases. C. Uses adult diapers, for "just in case". D. Drinks citrus juices and carbonated beverages. E. Performs pelvic muscle exercises.
b,e
Clients should be taught that repeatedly ignoring the sensation of needing to defecate could result in which of the following? A. Constipation B. Diarrhea C. Incontinence D. Hemorrhoids
constipation
the nurse will need to assess the client's performance of clean intermittent self catheterization (CISC) for a client with which urinary diversion? A. Ileal conduit B. Kock pouch C. Neobladder D. Vesicostomy
kock pouch
Using the principles of standard precautions, the nurse would wear gloves in what nursing interventions? A. Providing a back massage. B. Feeding a client. C. Providing hair care. D. Providing oral hygiene.
providing oral hygeine
