Fundamentals - Basics

A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency? (Select all that apply.) 1.Diplopia 2.Skin rash 3.Leg cramps 4.Tachycardia 5.Muscle weakness

4.Tachycardia 5.Muscle weakness

A nurse is reinforcing teaching to an adolescent about type 1 diabetes and self-care. Which questions from the client indicate a need for additional teaching in the cognitive domain? (Select all that apply.) 1."What is diabetes?" 2."What will my friends think?" 3."How do I give myself an injection?" 4."Can you tell me how the glucose monitor works?" 5."How do I get the insulin from the vial into the syringe?"

1."What is diabetes?" 4."Can you tell me how the glucose monitor works?"

When meeting the unique preoperative teaching needs of an older adult, the nurse plans a teaching program based on the principle that learning: 1.Reduces general anxiety 2.Is negatively affected by aging 3.Requires continued reinforcement 4.Necessitates readiness of the learner

3.Requires continued reinforcement

A client is admitted to the hospital because of multiple chronic health problems. What is the priority nursing intervention at this time? 1.Advising the client to join a support group immediately after discharge. 2.Assuring the family that staff members will take care of the client's needs. 3.Reminding the client to keep medical follow-up appointments after discharge. 4.Conducting a multidisciplinary staff conference early during the client's hospitalization.

4.Conducting a multidisciplinary staff conference early during the client's hospitalization.

A client has been diagnosed as "brain dead". The nurse understands that this means that the client has: 1.no spontaneous reflexes. 2.shallow and slow breathing. 3.no cortical functioning with some reflex breathing. 4.deep tendon reflexes only and no independent breathing

no cortical functioning with some reflex breathing.

What nursing actions best promote communication when obtaining a nursing history? (Select all that apply.) 1.Establishing eye contact 2.Paraphrasing the client's message 3 .Asking "why" and "how" questions 4.Using broad, open-ended statements 5.Reassuring the client that there is no cause for alarm 6.Asking questions that can be answered with a "yes" or "no"

1.Establishing eye contact 2.Paraphrasing the client's message 4.Using broad, open-ended statements

A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client? 1.Evaluation 2.Data Collection 3.Nursing interventions 4.Proposed nursing care

1.Evaluation

Place each step of the nursing process in the order that it should be used.

1.Obtain client's nursing history. 2.State client's nursing needs 3.Identify goals for care 4.Develop a plan of care. 5.Implement nursing interventions

A nurse assesses the vital signs of a 50-year-old female client and documents the results. Which of the following are considered within normal range for this client? (Select all that apply.) 1.Oral temperature 98.2° F 2.Apical pulse 88 beats per minute and regular 3.Respiratory rate of 30 per minute 4.Blood pressure 116/78 mm Hg while in a sitting position 5.Oxygen saturation of 92%

1.Oral temperature 98.2° F 2.Apical pulse 88 beats per minute and regular 4.Blood pressure 116/78 mm Hg while in a sitting position

A client who has reached the stage of acceptance in the grieving process appears peaceful, but demonstrates a lack of involvement with the environment. How should the nurse address this behavior? 1.Ignore the client's behavior when possible. 2.Accept the behavior the client is exhibiting. 3.Explore the reality of the situation with the client. 4.Encourage participation within the client's environment

2.Accept the behavior the client is exhibiting.

A female client explains to the nurse that she sleeps until noon every day and takes frequent naps during the rest of the day. What should the nurse do initially? 1.Encourage her to exercise during the day 2.Arrange a referral for a thorough medical evaluation 3.Explain that this behavior is an attempt to avoid facing daily responsibilities 4.Identify that the client is describing clinical findings associated with narcolepsy

2.Arrange a referral for a thorough medical evaluation

A nurse is caring for a client who has paraplegia as a result of a spinal cord injury. Which rehabilitation plan will be most effective for this client? 1.Arrangements will be made by the client and the client's family. 2.The plan is formulated and implemented early in the client's care. 3.The rehabilitation is minimal and short term because the client will return to former activities. 4.Arrangements will be made for long-term care because the client is no longer capable of self-care

2.The plan is formulated and implemented early in the client's care