Intro final exam
Exam 3
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Which risk factor for cardiopulmonary disease should the nurse describe as modifiable? Family history Allergies Stress Gender
Stress
A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? "Documentation provides information for a client audit." "Documentation allows providers to monitor the nurse's activities." "Documentation provides information to the client about financial charges for care provided." "Documentation is a communication tool for the interprofessional health care team."
"Documentation is a communication tool for the interprofessional health care team."
A patient diagnosed with hypertension asks the nurse how this disease could have happened to them. What is the nurse's best response? "Hypertension can happen from eating a poor diet, so change what you are eating." "Hypertension happens to everyone sooner or later. Don't be concerned about it." "Hypertension can happen from arterial changes that block the blood flow." "Hypertension happens when people do not exercise, so you should walk every day."
"Hypertension can happen from arterial changes that block the blood flow."
The nurse makes a home visit to a client recovering from influenza. Which client statements indicate that desired outcomes have been met? Select all that apply. "I haven't had chills since I left the hospital." "I was able to take a walk today." "I went back to work." "I slept the whole night without coughing." "I'm eating healthy foods now."
"I haven't had chills since I left the hospital." "I slept the whole night without coughing."
A nurse is leading a therapeutic group for clients at an outpatient mental health clinic. Which of the following client statements indicates a problem with role transition? "I want to have an intimate relationship, but I end up breaking off relationships as soon as they begin." "If my husband had gone to the doctor like I told him to, he'd be alive today." "I am so angry with my husband's attitude. He thinks he knows everything!" "I just can't seem to find any energy to take care of my children since my husband divorced me."
"I just can't seem to find any energy to take care of my children since my husband divorced me."
The nurse is reviewing discharge instructions for a client diagnosed with urinary incontinence resulting from a urinary tract infection. Which statement made by the client indicates the need for further education? "I will continue to hold my urine while in public so that I do not get another infection." "I will contact the healthcare provider prior to taking over-the-counter medications while on my antibiotic." "Drinking cranberry juice will decrease the risk for developing urinary tract infections." "I should drink plenty of water to prevent damage to my kidneys while I am on the antibiotics for the infection."
"I will continue to hold my urine while in public so that I do not get another infection."
A client is admitted to the hospital with an elevated temperature, nausea, and pain and tenderness in the lower right quadrant of the abdomen. After receiving pain medication, the client continues to complain of pain at a level of 8 on a 0-10 pain scale. The client is not scheduled to receive pain medications for at least another 2 hours. Given these circumstances, which statement by the nurse is most appropriate? "Let's try a heating pad or warm blanket to see if that helps with your discomfort." "Try to rest for a while longer until it is time to receive your medication" "I will inform the healthcare provider about your continued pain." "I do not have any medications ordered for you at this time."
"I will inform the healthcare provider about your continued pain."
A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for further teaching? "I will need to take a pain medication daily." "I will need to wipe my perineal area from back to front after urination." "I will need to empty my bladder regularly and completely." "I need to drink 8 cups of liquid each day."
"I will need to wipe my perineal area from back to front after urination."
The nurse is providing care to a client who ignores the urge to defecate when at work. The client states, "I don't like to have a bowel movement anywhere but at home." Which response by the nurse is the most appropriate? "You will get the urge later, so you should not worry about it." "If you continue to ignore the urge to defecate, it can lead to problems." "This is a common practice, and it will strengthen the reflex later." "It is better to suppress the urge than to suffer embarrassment at work."
"If you continue to ignore the urge to defecate, it can lead to problems."
A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? "Information about a client can be disclosed to family members at any time." "HIPAA is a federal law, not a state law." "HIPAA established regulations of individually identifiable health information in verbal, electronic, or written form." "A client's address would be an example of personally identifiable information."
"Information about a client can be disclosed to family members at any time."
A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband." Which of the following is a therapeutic nursing response? "Tell me what is concerning you." "Your husband is making really good progress." "Crying helps us let things out and we feel better." "Did your husband say something to upset you?"
"Tell me what is concerning you."
A nurse is teaching a school-age child who has type 1 diabetes mellitus and his parents about illness management. Which of the following instructions should the nurse include? "Notify the provider if blood glucose levels are over 350 milligrams/deciliter." "Test the urine for ketones." "Limit fluid intake during meal time." "Withhold insulin dose if feeling nauseous."
"Test the urine for ketones."
A nurse is planning to use the SBAR communication tool when calling a provider. Which of the following statements should the nurse include in the B step? "The client was found unconscious on the floor in her home." "The client should be seen by a neurologist." "The client is disoriented. Pupils are slow to respond to light." "There are no provider's prescriptions available."
"The client was found unconscious on the floor in her home."
A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client? Lactated Ringer's This is an isotonic IV solution, which will not help correct the client's sodium elevation. Dextrose 5% in 0.9% sodium chloride 0.45% sodium chloride Dextrose 10% in water
0.45% sodium chloride
A nurse is teaching a patient about hypertension. In which order from first to last will the nurse implement the steps of the teaching process? 1. Set mutual goals for knowledge of hypertension. 2. Teach what the patient wants to know about hypertension. 3. Assess what the patient already knows about hypertension. 4. Evaluate the outcomes of patient education for hypertension. 3, 2, 1, 4 2, 3, 1, 4 3, 1, 2, 4 1, 3, 2, 4
3, 1, 2, 4
A nurse is admitting a client who is dehydrated. Which of the following BUN levels should the nurse expect the client to have upon admission? 3.1 mg/dL 10 mg/dL 16.5 mg/dL 35 mg/dL
35 mg/dL
The nurse knows to keep a close eye on vitals of the patient that has pneumonia because it is an infection. What vitals would signify that the patient has gone septic? 80/40 120/80 166/75 200/99
80/40
exam 2
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A nurse is caring for a group of patients. Which patient will the nurse see first? A 17-year-old male who has just returned from outside "for a smoke" who needs a temperature taken An 87-year-old male suspected of hypothermia whose temperature is below normal Correct! A 20-year-old male postoperative patient whose blood pressure went from 128/70 to 100/60 A 27-year-old male patient reporting pain whose blood pressure went from 124/70 to 130/74
A 20-year-old male postoperative patient whose blood pressure went from 128/70 to 100/60
A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report? The nurse identifies a broken piece of equipment. A client discovers that his dentures are missing. A staff member does not show up to work her assigned shift. The nurse has a disagreement with the nursing supervisor about inadequate staffing.
A client discovers that his dentures are missing.
A nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that which of the following clients is at risk for metabolic acidosis? A client who is taking a thiazide diuretic A client who has diarrhea A client who is vomiting Respiratory depression
A client who has diarrhea
Which assessment finding will cause the nurse to begin teaching a patient because the patient is ready to learn? A patient has sufficient upper body strength to move from a bed to a wheelchair. A patient with a below-the-knee amputation is motivated about how to walk with assistive devices. A patient has normal eyesight to identify the markings on a syringe and coordination to handle a syringe. A patient has the ability to grasp and apply the elastic bandage.
A patient with a below-the-knee amputation is motivated about how to walk with assistive devices.
A nurse is caring for a group of patients. Which patient should the nurse see first? A patient with hypercapnia wearing an oxygen mask A patient with a new tracheostomy and tracheostomy obturator at bedside A patient with a chest tube ambulating with the chest tube unclamped A patient with thick secretions being tracheal suctioned first and then orally
A patient with a new tracheostomy and tracheostomy obturator at bedside
A nurse conducted a class on fall prevention for a group of older adult clients in the community. Which observation during a client home visit indicates that teaching on fall prevention was effective? A shower seat was placed in the shower. The locks were changed on the doors. All meat is placed in the freezer. Scatter rugs are placed in the kitchen.
A shower seat was placed in the shower.
A nurse exchanges information with the oncoming nurse about a patient's care. Which action did the nurse complete? A referral An electronic record entry An acuity rating A verbal report
A verbal report
What is the nursing process in order? Assessment, Diagnosis, Planning, Implementation, Evaluation Assessment, Planning, Diagnosis, Implementation, Evaluation Assessment, Planning, Evaluation, Diagnosis, Implementation Planning, Assessment, Implementation, Evaluation, Diagnosis
Assessment, Diagnosis, Planning, Implementation, Evaluation
The nurse caring for an adult client from another country notices that the client consults with her mother on all healthcare decisions. What action by the nurse is the most culturally competent? Confront the client's mother to state the importance of the client making her own decisions. Ask the client why the parent is being consulted for every decision. Accept the behavior of the client and family member. Ask the client's mother to leave the room to provide the client with more privacy.
Accept the behavior of the client and family member.
When a nurse performs or observes nursing practices that are not safe, the nurse has a responsibility to report those actions. This principle ties the concept of safety to what other nursing concept? Accountability Clinical Decision Making Advocacy Assessment
Accountability
A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect? Malignant hypertension Blood glucose level below 40 mg/dL Acetone or fruity odor to breath Cheyne-Stokes breathing
Acetone or fruity odor to breath
A client is recovering from surgery to repair a fractured hip. Which actions by the nurse may reduce this client's risk for osteomyelitis in the postoperative period? Select all that apply. Administer antibiotics as prescribed. Use sterile technique for dressing changes. Assess for pain every 1-2 hours. Assess wound for size, color, and drainage. Administer anticoagulants as prescribed.
Administer antibiotics as prescribed. Use sterile technique for dressing changes. Assess wound for size, color, and drainage.
The nurse is caring for a patient who has had a tracheostomy tube inserted. Which nursing intervention is most effective in promoting effective airway clearance? Suctioning respiratory secretions several times every hour Deflating the tracheostomy cuff before allowing the patient to cough up secretions Administering humidified oxygen through a tracheostomy collar Instilling normal saline into the tracheostomy to thin secretions before suctioning
Administering humidified oxygen through a tracheostomy collar
Which nursing intervention exemplifies the nurse working in a health promotion role? Select all that apply. Obtaining a blood glucose sample on a client with hypoglycemia Administering an inhaler to a client with asthma Administering vaccines to a well child Administering a prescribed antibiotic Reinforcing desirable changes to the client's lifestyle
Administering vaccines to a well child Reinforcing desirable changes to the client's lifestyle
The nurse at a health fair is educating clients on risk factors associated with urinary incontinence. Which risk factor does the nurse include as a nonmodifiable risk factor for urinary incontinence? Obesity Smoking Diabetes Age
Age
A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown? Check the client's skin every 8 hr for signs of breakdown. Apply a moisture barrier ointment to the client's skin. Request a prescription for the insertion of an indwelling urinary catheter. Clean the client's skin and perineum with hot water after each episode of incontinence.
Apply a moisture barrier ointment to the client's skin.
Which action by the novice nurse demonstrates commitment to a new job on a busy cardiac care unit? Joining the American Nurses Association (ANA) Arriving at every shift on time Questioning the preceptor during all procedures Exhibiting clinical competence
Arriving at every shift on time
The urgent care clinic nurse is treating a patient who is experiencing abdominal pain. The patient states, "I think I ate tainted food last night." What should the nurse do after the patient states that the food was tainted? Tell the patient the healthcare provider does not need to assess the client. Call an ambulance before assessing the client any further. Advise the client to take an antacid. Ask the patient open-ended questions to further assess the situation.
Ask the patient open-ended questions to further assess the situation.
The nurse is developing a plan of care for a client who is at risk for falls. Which interventions would be appropriate for the nurse to include in the plan of care? Select all that apply. Let the patient place a rug on the floor to keep their feet warm Assess the client's vision and make sure he is using any prescribed eyewear. Keep frequently used items within easy reach. Apply physical restraints if the client gets out of bed. Use side rails on client beds.
Assess the client's vision and make sure he is using any prescribed eyewear. Keep frequently used items within easy reach. Use side rails on client beds.
Vital signs for a patient reveal a high blood pressure of 187/100. Orders state to notify the health care provider for diastolic blood pressure greater than 90. What is the nurse's first action? Follow the clinical protocol for a stroke. Assess the patient for other symptoms or problems, and then notify the health care provider. Review the most recent lab results for the patient's potassium level. Administer an antihypertensive medication from the stock supply, and then notify the health care provider.
Assess the patient for other symptoms or problems, and then notify the health care provider
A nurse is caring for an older adult client who has a terminal illness and is ventilator-dependent. The client is alert and oriented and he wants to discontinue use of the ventilator. The nurse should be aware that continued treatment against the client's wishes is a violation of which of the following ethical principles? Autonomy Justice Fidelity Veracity
Autonomy
The nurse is instructing a client on lifestyle changes to promote a healthy cardiovascular system. Which of the following should be included in this teaching session? Select all that apply. Limit exercise to 15 minutes a day Wear elastic hose Avoid cigarette smoking Reduce saturated fats in the diet
Avoid cigarette smoking Reduce saturated fats in the diet
List the pathophysiologic processes involved in appendicitis in sequential order. A) The appendix becomes distended with fluid secreted by its mucosa. B) The proximal lumen of the appendix becomes obstructed. C) Purulent exudate forms and causes further distention of the appendix. D) Pressure within the lumen of the appendix increases. E) Tissue necrosis occurs and gangrene develops. (List the letters in order with a comma and a space between each letter. For example: Z, Y, X, P, L )
B, A, D, C, E
The nurse is prioritizing care for a client with several problems. List the order in which the nurse should address the client's needs. answer with comma between each letter A) Bleeding through nasogastric tube B) Audible wheezes C) Not understanding how to complete the menu D) Requesting medication for arthritis pain E) Dyspnea F) Asking questions about teaching provided the other day
B, E, A, D, F, C
A patient's serum electrolytes are being monitored. The nurse notices that the potassium level is low. What should the nurse monitor for in this patient? Tissue ischemia Cardiac dysrhythmia Brain malformations Intestinal blockage
Cardiac dysrhythmia
The patient is found to be unresponsive and not breathing. Which pulse site will the nurse use? Apical Carotid Brachial Radial
Carotid
A home health nurse is planning care for an adult client who is being discharged from the hospital after experiencing complications of diabetes mellitus. The client requires an extensive dressing change twice per day, help with activities of daily living, and comprehensive education. To ensure these needs are met, the nurse is coordinating home visits from aides and therapists. Which role is the nurse assuming by coordinating this client's care? Health promoter Health educator Case manager Client advocate
Case manager
A nurse wants to reduce data entry errors on the computer system. Which action should the nurse take? Chart on the computer immediately after care is provided. Print out and review computer nursing notes at home. Share password with only one other staff member. Use the same password all the time.
Chart on the computer immediately after care is provided.
A patient is admitted with shortness of breath. Which action should the nurse take first? Check pulse oximetry Administer oxygen Listen to heart Administer lasix
Check pulse oximetry
The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD). Which clinical manifestations are the direct result of altered perfusion? Select all that apply. Confusion Pink nail beds Cyanosis Bounding pulse
Confusion Cyanosis
A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select all that apply.) Contractures of the extremities Diarrhea Polyuria Crackles in lungs Pressure ulcers
Contractures of the extremities Crackles in lungs Pressure ulcers
A client has an excoriated skin area with purulent drainage. Which diagnostic test does the nurse anticipate being ordered? Patch test Skin biopsy Culture Wood's lamp
Culture
The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD). Which factors in the client's history support the current diagnosis? Select all that apply. Current cigarette smoking Working in an office setting with air conditioning History of asthma Working in an industrial environment Playing golf several times a week
Current cigarette smoking History of asthma Working in an industrial environment
The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia? Elevated blood pressure Restlessness Cyanosis Increased pulse rate
Cyanosis
L.G. is hospitalized with a COPD exacerbation. The nurse knows that in order to prevent pneumonia in this patient, they should promote the following: Short breaths Apnea Deep breathing a coughing Lying flat on back
Deep breathing a coughing
The nurse is planning care for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which interventions should the nurse select to address the client's ineffective breathing pattern? Select all that apply. Deep breathing and coughing every hour Instruct in pursed-lip breathing Provide oxygen 2 liters nasal cannula. Instruct in abdominal breathing Teach visualization and meditation
Deep breathing and coughing every hour Instruct in pursed-lip breathing Instruct in abdominal breathing Teach visualization and meditation
The nurse is caring for an older adult client. The client tells the nurse that he is constipated. What is the nurse's initial action? Determine what the client means by constipation. Obtain an order for a laxative and an enema from the physician. Assess the client's intake of fiber and fluids. Encourage the client to increase fluid intake and activity.
Determine what the client means by constipation.
Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.) Set priorities for patient care. Ambulate patient 25 feet in the hallway. Determine whether outcomes or standards are met. Document results of goal achievement. Use self-reflection and correct errors.
Determine whether outcomes or standards are met. Document results of goal achievement. Use self-reflection and correct errors.
A patient diagnosed with chronic emphysema (lung disease) states "I would be better off dead." The nurse learns that the patient, has recently become unemployed because of oxygen dependency. The patient's spouse will have to go to work to support the family. Which action should the nurse take? Assure the patient that things will work out. Develop a plan of care for the family. Contact psychiatric services for a referral. Focus the plan of care solely on maximizing patient function.
Develop a plan of care for the family.
Clients experiencing diarrhea often lose electrolytes. Which of the following best describes the reason for this loss? Decreased secretion of intestinal mucus inhibits the absorption of electrolytes from the chyme by the intestine. Intestinal bacteria break down electrolytes during diarrhea and make them unfit for absorption by the intestine. Diarrhea causes rapid passage of chyme through the large intestine, reducing the time available for absorption of electrolytes. Pathogenic microorganisms that cause diarrhea consume the electrolytes in the chyme, resulting in fewer electrolytes being available for absorption.
Diarrhea causes rapid passage of chyme through the large intestine, reducing the time available for absorption of electrolytes.
The nurse is providing care to an adult client with a long history of chronic obstructive pulmonary disease (COPD). The client is admitted to the intensive care unit with a pneumothorax. Which interventions are appropriate for this client? Select all that apply. Elevate head of the bed Prepare for a chest tube insertion Administer intravenous caffeine per order Administer a high rate of oxygen by nasal cannula like 8 L Administer prescribed antihypertensive medications
Elevate head of the bed Prepare for a chest tube insertion
The nurse notices that a client, who is from another country, appears uncomfortable when the nurse asks to look at the client's abdominal incision from a recent surgery. Which nursing action is the most culturally competent? Close the client's curtain to maintain privacy. Ask the client to explain why she is uncomfortable. Wait until the next assessment time to observe the incision. Explain the reason for the intervention using lay terms.
Explain the reason for the intervention using lay terms.
A nurse is caring for a client on the medical-surgical unit. The client has been taking warfarin at home and her laboratory values reveal her INR is 3.5 (should be 2-3 on warfarin therapy). The client states she is checking herself out of the hospital and refuses to wait until her provider can discuss the situation with her. Which of the following actions should the nurse take? Tell the client she will not be permitted to leave the facility until she has signed the against medical advice (AMA) form. Ask the security department to guard the room to the client's door. Tell the client if she leaves without a written prescription for discharge, her insurance will not pay for the facility visit. Explain the risk the client faces if she leaves the facility.
Explain the risk the client faces if she leaves the facility.
A nurse is caring for a client who is confused and uncooperative. The client hit the nurse when she attempted to give him his medication. The nurse asks the charge nurse if she can restrain the client. The charge nurse should tell the nurse this action is a violation of the client's rights and is an example of which of the following? Invasion of privacy False imprisonment Defamation of character Slander
False imprisonment
A home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic? Fatigue and muscle weakness Oliguria Pitting edema Dyspnea
Fatigue and muscle weakness
The nurse makes a medication error. The nurse assessed the patient. The nurse then notified the doctor, floor manager, and the patient's family. What is the next step for the nurse to take? Fill out an unusual occurrence form for quality control Ask the patient not to tell anyone Take care of the next patient Feed the patient
Fill out an unusual occurrence form for quality control
Which of the following individuals is widely considered to be the founder of nursing? Florence Nightingale Mary Mahoney Lavinia Dock Linda Richards
Florence Nightingale
Which position means the head of the bed is elevated 45-60 degrees and the patient's knees are slightly elevated? sims prone supine Fowler's
Fowler's
A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following pieces of personal protective equipment (PPE) should the nurse remove first? Gown Gloves Mask Face shield
Gloves
A nurse is teaching the staff about health care reimbursement. Which information should the nurse include in the teaching session? HIPAA is the basis for establishing reimbursement for health care. Home health, long-term care, and hospital nurses' documentation can affect reimbursement for health care. A clinical information system must be installed by 2014 to obtain health care reimbursement. A "near miss" helps determine reimbursement issues for health care.
Home health, long-term care, and hospital nurses' documentation can affect reimbursement for health care.
The warmth and redness that accompany inflammation result from which of the following steps in the inflammatory process? Hyperemia Exudate production Cellular regeneration Margination of leukocytes
Hyperemia
The nurse is caring for a patient who has a bloodborne pathogen. The nurse splashes blood above the glove to intact skin while discontinuing an intravenous (IV) infusion. Which step(s) will the nurse take next? Obtain an alcohol swab, remove the blood with an alcohol swab, and continue care. Do nothing; accidentally getting splashed with blood happens frequently and is part of the job. Immediately wash the site with soap and running water, and seek guidance from the manager. Delay washing of the site until the nurse is finished providing care to the patient.
Immediately wash the site with soap and running water, and seek guidance from the manager.
A nurse is giving a presentation about preventing deep-vein thrombosis (DVT). Which of the following should the nurse include as a risk factor for this disorder? (Select all that apply.) Immobility Acid reflux Oral contraceptive use Hypotension
Immobility Oral contraceptive use
The nurse is caring for a client with functional incontinence. Which conditions are factors in the development of this type of incontinence? Select all that apply. Fecal impaction Prostate surgery Dementia Confusion Impaired mobility
Impaired mobility
A nurse is providing nursing care to patients after completing a care plan from nursing diagnoses. In which step of the nursing process is the nurse? Assessment Evaluation Planning Implementation
Implementation
The nurse is concerned that a client with an alteration in perfusion is at risk for inadequate oxygenation. What should the nurse consider when planning for this client's potential health problem? Encouraging ambulation every 30 minutes Instructing on deep breathing Positioning to increase blood return Administering medications appropriate to increase heart rate
Instructing on deep breathing
A nurse is reviewing a client's lab results. Which of the following lab values should the nurse report to the provider? Sodium 126 mEq/L Magnesium 1.9 mEq/L Chloride 99 mEq/L Potassium 3.6 mEq/L
Sodium 126 mEq/L
Inadequate fluid intake slows the passage of chyme along the intestines. This slowed passage increases the absorption of fluid from the chyme. How does this decreased intake and increased passage time affect the feces expelled from the body? It is more watery and more soft than normal. It is drier and more soft than normal. It is drier and harder than normal. It is more watery and harder than normal.
It is drier and harder than normal.
A nurse is caring for a group of clients. The nurse demonstrates adherence to the ethical principle of fidelity by doing which of the following? Keeping an appointment with a client Refusing to disclose information about a client to the media Allowing a new mother to hold her stillborn infant Confirming that a client going for surgery has signed a consent form
Keeping an appointment with a client
An 84-year-old client with poor skin turgor has slipped down in the hospital bed. Which action by the nurse is appropriate to safely reposition this client to prevent further skin breakdown? Placing the bed in reverse Trendelenburg position Using the bed sheet to slide the client up in bed Lifting the client, using the client's legs and arms for assistance Using the client's arms to pull the client up in bed
Lifting the client, using the client's legs and arms for assistance
The nurse is concerned that a client is at risk for pressure injuries. Which assessment data supports the nurse's concern? Select all that apply. Low serum albumin level Continence of urine and stool Prescribed bedrest Age 54 Body temperature within normal limits
Low serum albumin level Prescribed bedrest
A nurse accidentally administers the wrong medication to a client, which results in a severe allergic reaction and prolongs the client's hospitalization. The client could rightfully sue the nurse for which of the following? Assault Abuse Malpractice Battery
Malpractice
A nurse is caring for a client who has the following arterial blood gas results: HCO3 18 mEq, PaCO2 28 mm Hg and pH 7.30. The nurse recognizes the client is experiencing which of the following acid base imbalances? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis
Metabolic acidosis
R.R. came in with DKA and is confused and lethargic. ABGs are the following: PH 7.25 CO2 48 HCO3 15 What acid base problem does R.R. exhibit? Metabolic acidosis uncompensated Metabolic acidosis partially compensated Respiratory acidosis partially compensated Respiratory acidosis uncompensated
Metabolic acidosis partially compensated
A nurse is admitting a client who has been vomiting excessively and is reporting numbness and tingling of the toes and fingers. The nurse should recognize the client is experiencing which of the following acid-base imbalances? Respiratory alkalosis Respiratory acidosis Metabolic acidosis Metabolic alkalosis
Metabolic alkalosis
A nurse is caring for a client who is experiencing severe nausea and vomiting after a course of chemotherapy. The nurse should monitor the client for which of the following clinical manifestations? Metabolic alkalosis Respiratory acidosis Metabolic acidosis Respiratory alkalosis
Metabolic alkalosis
A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.) Minimize skin exposure to moisture. Use pillows to keep heels off the bed surface. Massage over erythematous bony prominences. Implement turning schedule every 4 hr. Keep the client's skin dry with powder.
Minimize skin exposure to moisture. Use pillows to keep heels off the bed surface.
A nurse is assessing a preschooler who has a calcium level of 8.0 mg/dL. Which of the following findings should the nurse expect? Muscle tremors Negative Chvostek's sign Dry, sticky mucous membranes Polyuria
Muscle tremors
The nurse is assessing a patient for the adequacy of ventilation. What assessment findings would indicate the patient has good ventilation? (Select all that apply.) The right side of the thorax expands slightly more than the left. Nail beds are pink with good capillary refill. Respiratory rate is 24 breaths/min. Oxygen saturation level is 98%. Trachea is just to the left of the sternal notch. There is presence of quiet, effortless breath sounds at lung base bilaterally.
Nail beds are pink with good capillary refill. Oxygen saturation level is 98%. There is presence of quiet, effortless breath sounds at lung base bilaterally.
A nurse is caring for a patient diagnosed with chronic obstructive pulmonary disease (COPD) who is receiving 2 L/min of oxygen. Which oxygen delivery device is most appropriate for the nurse to administer the oxygen? Non-rebreather mask Nasal cannula Simple face mask Partial non-rebreather mask
Nasal cannula
A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data? Cyanosis Blood pressure Petechiae Nausea
Nausea
A nurse is assessing a client who has a sodium level of 116 mEq/L. Which of the following findings should the nurse expect? Fever Extreme thirst Nausea and vomiting Flushed skin
Nausea and vomiting
The nurse would identify which body systems as directly involved in the process of normal gas exchange? (Select all that apply.) Neurologic system Pulmonary system Cardiovascular system Immune system Endocrine system Hepatic system
Neurologic system Pulmonary system Cardiovascular system
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? Veracity Utilitarianism Nonmaleficence Fidelity
Nonmaleficence
The nurse asks a patient where the pain is, and the patient responds by pointing to the area of pain. Which form of communication did the patient use? Verbal Nonverbal Intonation Vocabulary
Nonverbal
The nurse discovers a patient on the floor. The patient states that he fell out of bed. The nurse assesses the patient and places the patient back in bed. Which action should the nurse take next? Assess the patient. Do nothing, no harm has occurred. Complete an incident report. Notify the health care provider.
Notify the health care provider.
A client in the intensive care unit is combative and pulling at the endotracheal tube, which must remain in place. After exhausting all alternatives, the nurse applies soft restraints to protect the client's airway. Which action should the nurse take next? Document the application of restraints in the chart. Notify the family of the need for restraints. Reassess the need for the restraints in 8 hours. Notify the primary healthcare provider.
Notify the primary healthcare provider.
A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take? Advise the client to add citrus juices and bananas to her diet. Obtain a blood sample for a serum sodium level. Obtain a 12-lead ECG. Suggest that the client use a salt substitute.
Obtain a 12-lead ECG.
A complaint about unsafe working conditions should be reported to which agency? Occupational Safety and Health Administration American Nurses Association National Institute for Occupational Safety and Health State board of nursing
Occupational Safety and Health Administration
A nurse is assessing a client who has a urine output of 250 mL in a 24-hr period. Which of the following descriptive terms should the nurse place in the client's electronic record? Nocturia Oliguria Enuresis Anuria
Oliguria
A nurse is assessing a patient who has left sided heart failure. Which of the following findings should the nurse expect? Weight loss Bradycardia Increased urine output Orthopnea
Orthopnea
Which of the following is fully compensated? PH 7.20 CO2 21 HCO3 16 PH 7.37 CO2 32 HC03 35 PH 7.25 CO2 68 HCO3 31 PH 7.54 CO2 25 HCO3 22
PH 7.37 CO2 32 HC03 35
A nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the nurse expect? HCO3- 30 mEq/L Potassium 3.3 mEq/L pH 7.45 PaCO2 50 mm Hg
PaCO2 50 mm Hg
A nurse is completing a physical assessment of a client who has early osteoarthritis. Which of the following manifestations should the nurse expect? Pain worsens with activity Increased urination Confusion Diarrhea
Pain worsens with activity
A nurse is planning an in-service on preventing infection for the staff nurses on a hospital's medical-surgical unit. Which of the following should be the priority teaching point for this in-service? Raising the temperature in each client's room Performing hand hygiene Assessing vital signs once daily Wearing a mask for client care
Performing hand hygiene
The patient is brought to the emergency department after a motor vehicle accident. The patient is diagnosed with internal bleeding. What is the priority of care for this patient? Reaction to medications Mental alertness Pain Perfusion
Perfusion
Which determination is the nurse trying to achieve by monitoring a patient's cardiac output? Ventilation status Peripheral extremity circulation Presence of cardiac dysrhythmias Oxygenation requirements
Peripheral extremity circulation
According to Maslow's hierarchy, the "order of client needs goes , , Love and belonging , , " starting with physiological at level 1 Safety and Security Physiological Self-Esteem Self Actualization Love and belonging
Physiological Safety and Security Love and belonging Self-Esteem Self Actualization
The nurse is providing care to a client with asthma. When developing the client's plan of care, which intervention would be most appropriate to promote effective gas exchange? Provide adequate rest periods Place in Fowler position Assist with activities of daily living Reduce excessive stimuli
Place in Fowler position
A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? Provide the client with a diet high in protein. Reposition the client every 3 hr. Massage bony prominences to promote circulation. Apply cornstarch to keep the skin dry.
Provide the client with a diet high in protein.
R.H. is in heart failure exacerbation. What vital signs would he most likely have? Pulse Ox 76%, HR 80, BP 135/86, Respirations 18 Pulse Ox 88%, HR 82, BP 178/82, Respirations 12 Pulse Ox 77%, HR 112, BP 162/98, Respirations 28 Pulse Ox 98%, HR 100, BP 120/80, Respirations 20
Pulse Ox 77%, HR 112, BP 162/98, Respirations 28
The nurse is positioning a client with left-sided heart failure in bed. Which sleeping position is most appropriate for this client? Lying on the left side with 1 pillow under head Lying supine with 1 pillow under head Lying in the Sims position with 2 pillows under head Reclining with 3 pillows under head
Reclining with 3 pillows under head
The nurse is caring for a client who is admitted with cellulitis of the foot. Which assessment findings support this diagnosis? Breath sounds Blood urea nitrogen (BUN) and creatinine Redness, pain, and edema at the site Blood cultures
Redness, pain, and edema at the site
A patient has an ankle restraint applied. Upon assessment the nurse finds the toes a light blue color. Which action should the nurse take next? Place a blanket over the feet. Take the patient's blood pressure, pulse, temperature, and respiratory rate. Immediately do a complete head-to-toe neurologic assessment. Remove the restraint.
Remove the restraint.
While performing nasotracheal suctioning, the nurse notes the older adult client with an alteration in oxygenation is moving the head around and pulling at the nurse's hand to remove the suction catheter. Which actions by the nurse are appropriate? Select all that apply. Remove the suction catheter Hyperoxygenate the client Decrease the suction pressure Apply restraints to the client's arms and legs Lower the head of the bed
Remove the suction catheter Hyperoxygenate the client Decrease the suction pressure
An older adult client with poor nutritional intake is demonstrating signs of poor wound healing. Which intervention best addresses the client's nutritional needs? Encourage ambulation. Assist with deep-breathing exercises. Request a dietary consult. Medicate for pain prior to dressing changes.
Request a dietary consult.
A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Saturation 80% Bicarbonate 26 mEq/L Metabolic alkalosis Respiratory acidosis Respiratory alkalosis Metabolic acidosis
Respiratory acidosis
The nurse is planning care for a client experiencing dyspnea and a subsequent activity intolerance. Which action by the nurse is the most appropriate? Space periods of activity with periods of rest. Encourage dependence with activities of daily living. Encourage strenuous activity. Consult a dietitian for low-calorie meals.
Space periods of activity with periods of rest.
The nurse is caring for a client with a self-reported latex allergy. Which strategy can the nurse use to ensure the safety of this client? Wear hypoallergenic gloves Keep beta adrenergic agonists on hand Wear gloves with powder Wash hands after taking gloves off
Wash hands after taking gloves off
The nurse is preparing to triage victims of a train derailment who are being transported to the emergency department. Which victims would need immediate care? Select 2 that apply. Bleeding from superficial facial wounds and talking to family Holding broken arm, sitting in a chair Walking with a slight limp, asking for something to drink Respiratory rate of 8 and irregular Bleeding from fractured limb with a blood pressure of 78/40 mmHg
Respiratory rate of 8 and irregular Bleeding from fractured limb with a blood pressure of 78/40 mmHg
A nurse uses the five rights of medication administration. What are they? Right cost-effectiveness Right dose Right medication Right bed Right patient Right route Right time
Right dose Right medication Right patient Right route Right time
A nurse is teaching a health class about the heart. Which information from the class members indicates teaching by the nurse is successful for the flow of blood through the heart, starting in the right atrium? Left atrium, left ventricle, right ventricle Left atrium, right ventricle, left ventricle Right ventricle, left ventricle, left atrium Right ventricle, left atrium, left ventricle
Right ventricle, left atrium, left ventricle
The nurse is planning care for a newly admitted bedbound older adult client. Which nursing diagnosis would be most appropriate for this client? Disturbed Body Image Risk for Constipation Risk of Bowel Incontinence Risk for Diarrhea
Risk for Constipation
A nurse is assessing a school-age child whose blood glucose level is 280 mg/dL. Which of the following findings should the nurse expect? Lethargy Pallor Tremors Shallow respirations
Shallow respirations
A nurse is documenting information in a computerized health record. Which of the following nursing actions jeopardizes client confidentiality? Preventing an unidentified health care worker from viewing a health record on the computer screen Sharing computer passwords with coworkers Using a computer terminal in a non-public area Logging out of the computer before leaving a terminal
Sharing computer passwords with coworkers
The nurse knows that the patient with a broken hip is at risk for orthostatic hypotension because of immobility. What should the nurse do? Sit the patient at the side of the bed before getting up Don't get the patient up Put the patient in Trendelenburg position for a few minutes before getting up Get the patient up quickly
Sit the patient at the side of the bed before getting up
After providing care, a nurse charts in the patient's record. Which entry will the nurse document? Apparently is asleep with eyes closed Skin pale and cool Appears restless when sitting in the chair Drank adequate amounts of water
Skin pale and cool
A nurse is performing an admission assessment on a client. Which of the following findings should the nurse identify as an indication that the client is dehydrated? Jugular vein distention Low body temperature Skin tenting present Blood pressure 178/90 mm Hg
Skin tenting present
Match the required PPE with the appropriate Precaution Label Standard Precautions Contact Precautions Droplet Precaution Airborne gloves, gown, mask, goggles, private room gloves, gown, private room gloves, private room gloves, gown, mask goggles, neg. pressure, private room
Standard Precautions- gloves, private room Contact Precautions- gloves, gown, private room Droplet Precaution- gloves, gown, mask, goggles, private room Airborne- gloves, gown, mask goggles, neg. pressure, private room
A school nurse is assessing an adolescent who reports feeling shaky and is having difficulty speaking and concentrating on the questions the nurse is asking. The nurse checks the adolescent's blood glucose level and identifies a value of 55 mg/dL. Which of the following findings should the nurse expect? Deep, rapid respirations Tachycardia Dry, flushed skin Polyuria
Tachycardia
The nurse is caring for a client with severe inflammation. Which assessment findings would indicate a systemic reaction to inflammation? Select all that apply. Edema Erythema Tachycardia Pain Tachypnea
Tachycardia Tachypnea
When providing care to a client with a wound, which evidence-based interventions should the nurse anticipate carrying out? Select all that apply. Keeping the wound dry Teaching the client that proper wound management can reduce scarring Keeping the wound covered Ensuring that the wound remains moist Only covering the wound if a scab forms
Teaching the client that proper wound management can reduce scarring Keeping the wound covered Ensuring that the wound remains moist
A nurse has just received the shift report for a 12-hour shift. As the nurse is preparing to enter a client's room, the nurse overhears a coworker telling an offensive joke with a sexual undertone to the client. Which action by the nurse is appropriate? Ask to be scheduled on a different shift than this coworker. Report the incident to the unit manager. Tell the coworker, in private, that such conduct is offensive and not professional. Ignore the coworker and walk away.
Tell the coworker, in private, that such conduct is offensive and not professional.
A nurse is reprimanded for being habitually late. What action by the nurse would best address this performance issue? The nurse must provide proof that all instances of tardiness were unavoidable. The nurse must take responsibility and accept any corrective action. The nurse must trade shifts in order to be on time. The nurse must have a positive attitude.
The nurse must take responsibility and accept any corrective action.
The nurse is presenting an in-service on the importance of collaborative communication. The nurse includes which critical event identified by the Joint Commission as an outcome of poor communication among healthcare team members? Increased time to discharge patients to outpatient care Decreased ability to document expenses of care provided The occurrence of a patient event resulting in death or serious injury Longer time to begin surgical cases
The occurrence of a patient event resulting in death or serious injury
A nurse receives a shift report and is preparing to care for patients assigned on a medical-surgical unit. Which patient should the nurse plan to assess first? The patient who needs help ambulating to the bathroom The patient experiencing shortness of breath The patient with a pain rating of 3/10 The patient who needs assistance with activities of daily living
The patient experiencing shortness of breath
When making rounds the nurse observes a purple wristband on a patient's wrist. How will the nurse interpret this finding? The patient is at risk for seizures. The patient is allergic to certain medications or foods. The patient has a high risk for falls. The patient has do not resuscitate preferences.
The patient has do not resuscitate preferences.
Which action by a student nurse is most consistent with commitment to the nursing profession? The student calls in sick for clinicals in order to study for a class exam. The student calls in sick for clinicals because of a respiratory infection. The student declines to observe a new procedure for giving a necessary bath. The student misses class to attend a political rally.
The student calls in sick for clinicals because of a respiratory infection.
A nurse preceptor is working with a student nurse. Which behavior by the student nurse will require the nurse preceptor to intervene? The student nurse shares patient information with a friend. The student nurse documents medication administered to the patient. The student nurse reviews the patient's medical record. The student nurse reads the patient's plan of care.
The student nurse shares patient information with a friend.
When you cut your finger, the inflammatory process begins. What happens first? Exudate is produced Vascular permeability increases and edema occurs from fluid, proteins, and leukocytes leaking into interstitial space Tissue releases chemicals like prostaglandins and histamine that cause vessel dilation, resulting in hyperemia New granulation tissue is formed
Tissue releases chemicals like prostaglandins and histamine that cause vessel dilation, resulting in hyperemia
A nurse uses SBAR when providing a hands-off report to the oncoming shift. What is the rationale for the nurse's action? To use common courtesy To standardize communication To establish trustworthiness To promote autonomy
To standardize communication
Which risk factor for hypertension is modifiable? Family history Ethnicity Tobacco use Age
Tobacco use
A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. Which of the following actions should the nurse take? Focus on the client's present circumstances instead of his personal stories. Verbalize understanding of how the client feels. Offer the client personal thoughts and beliefs. Use attentive listening with the client.
Use attentive listening with the client.
The patient is being admitted to the emergency department with reports of shortness of breath. The patient has had chronic lung disease for many years but still smokes. What will the nurse do? Administer high levels of oxygen. Use oxygen cautiously in this patient. Give CO2 via mask. Allow the patient to breathe into a paper bag.
Use oxygen cautiously in this patient.
The nurse is teaching a class on infection control. Which nursing measure is most appropriate in breaking a link in the chain of infection? Cover one's cough by placing the mouth in the hand. Use personal protective equipment (PPE). Place contaminated linens in a paper bag or on the floor. Wear sterile gloves for client care.
Use personal protective equipment (PPE).
A nurse is caring for a patient prescribed continuous cardiac monitoring for heart dysrhythmias. Which rhythm will cause the nurse to intervene immediately? Ventricular tachycardia Atrial flutter Sinus rhythm Atrial fibrillation
Ventricular tachycardia
A nurse administers an incorrect medication to a client. Following an assessment of the client, the nurse determines that the client has experienced no untoward effects as a result of the medication. The nurse does not complete an incident report because no harm came to the client. Which of the following ethical principles did the nurse violate? Confidentiality Beneficence Autonomy Veracity
Veracity
A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take? Wear protective eyewear. Wear sterile gloves. Wear an N95 respirator mask. Wear clean gloves.
Wear clean gloves.
G.H. has COPD and has respiratory acidosis. Which of the following should the nurse educate the patient on upon discharge? Wearing BIPAP at night Safe weight loss Avoiding hyperventilating Safe food handling
Wearing BIPAP at night
The nurse is caring for a client who is exhibiting signs of a systemic infection following surgery. Which diagnostic tests would the nurse anticipate being ordered? Select all that apply. White blood cell differential Wound culture Urinalysis Serum electrolyte levels White blood cell count
White blood cell differential Wound culture Urinalysis White blood cell count
B.P. is a 68 year old patient that came in with chest pain. Diagnostic tests were ordered. The results are the following: troponin 0.01 EKG normal sinus rhythm Vital signs: BP 140/86, HR 111, Respirations 26, Pulse Ox 77% on room air The patient's medical history: hypertension, asthma, sleep apnea All of the following are appropriate questions for the nurse to ask the patient to gain further information about the chest pain except... Why do you have chest pain? When did the chest pain start? What were you doing when the chest pain began? Have you had this pain before?
Why do you have chest pain?
The structure of the respiratory system that serves as the site of gas exchange is the macrophage. alveoli. bronchi. bronchiole.
alveoli.
B.P. is a 68 year old patient that came in with chest pain. Diagnostic tests were ordered. The results are the following: troponin 0.01 EKG normal sinus rhythm Vital signs: BP 140/86, HR 111, Respirations 26, Pulse Ox 77% on room air The patient's medical history: hypertension, asthma, sleep apnea Which of the following is B.P. likely experiencing? angina COPD exacerbation asthma exacerbation myocardial infarction (MI)
asthma exacerbation
The nurse is caring for the patient with left sided heart failure (CHF). Which of the following would be the highest priority assessment for this patient? palpate abdomen administer oxygen auscultate lungs skin dryness
auscultate lungs
To prevent antibiotic-resistant bacteria, the nurse should educate the patient to stop taking antibiotics when feeling better ask for antibiotics when you have the flu complete full prescription of antibiotics avoid antibiotics at all cost
complete full prescription of antibiotics
Because of the way the influenza virus is transmitted from person to person, nurses who are working with clients with influenza should implement isolation precautions. airborne precautions. droplet precautions. contact precautions.
droplet precautions.
A type of infection that is associated with the delivery of healthcare services in a facility such as a hospital or nursing home is called a(n) latent infection. healthcare-associated infection. community-associated infection. etiologic infection.
healthcare-associated infection.
A nurse has completed the planning step of the nursing process for a client who has an acid-base imbalance. Which of the following steps should the nurse take next? implementation analysis evaluation assessment
implementation
A nurse is assessing a client's abdomen who reports stomach pain. Which of the following actions should the nurse take first? auscultate inspect palpate percussterm-110
inspect
A nurse is performing passive range of motion on a client who had a stroke. The nurse should identify that passive range of motion is performed to increase which of the following? muscle strength bone density joint flexibility muscle mass
joint flexibility
A nurse is caring for a client who requires droplet precautions. Which of the following personal protective equipment should the nurse wear when setting up the client's meal tray? hair net goggles gown mask
mask
A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see? pH below 7.35 PaCO2 above 45 mm Hg HCO3 above 26 mEq/L PaO2 below 70 mm Hg
pH below 7.35
A nurse in a community health clinic is interviewing a couple who just lost their house in a fire. Using the priority framework of Maslow's hierarchy of needs, which category should the nurse identify for the clients' situation? self-actulaization esteem love and belonging physiological
physiological
A nurse is working with a social worker and a physical therapist in preparing a discharge projection for a client who is postoperative. Which of the following steps of the nursing process is the nurse engaging in? analysis evaluation assessment planning
planning
Which position is lying on the stomach? prone supine Sims Fowler's
prone
The nurse knows that because of CO2 retention, the patient with COPD is at risk for diabetes insipidus metabolic acidosis diabetes mellitus respiratory acidosis
respiratory acidosis
E.R. has peptic ulcer disease (PUD). He eats a well balanced diet that him and his wife cook together. He occasionally has a drink with vodka around once per week. He smokes half a pack of cigarettes per week. He walks their dog daily. Which education would be most appropriate to help this patient? eat a well balanced diet smoking cessation stop drinking alcohol increase exercise
smoking cessation
A charge nurse is reviewing guidelines for initiating airborne precautions. Which of the following clients should the nurse identify as requiring airborne precautions? influenza scabies tuberculosis MRSA
tuberculosis
Which of the following is the most common healthcare-associated infection? otitis media MRSA cellulitis urinary tract infection
urinary tract infection
