Learning System PN 3.0 (Term 1)-(set A)

A nurse is reviewing adult cardiopulmonary resuscitation (CPR) with a newly licensed nurse. Which of the following steps should the nurse identify as the first response when performing CPR?

-call for assistance. -Begin chest compressions -Confirm unresponsiveness -Give rescue breaths.

A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who may have a high ear infection. Which of the following routes should the nurse use to obtain the temperature?

-rectal -tympanic -oral -temporal

A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of following actions by the nurse demonstrate proper surgical hand-washing technique

-the nurse washes each part of her hands with five strokes -the nurse washes from the elbows down to the hands -the nurse washes with her hands held higher than her elbows -the nurse uses minimal friction when washing her hands

A nurse is instructing an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?

"There are times I should use soap and water rather than an alcohol-based hand rub to clean my hand." " I will use cold water when I wash my hands to protect my skin from becoming to dry." " I will apply friction for at least 10 seconds while washing my hands." "After washing my hands, I will dry them from the elbows down."

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?

Encourage the child to cough frequently to clear congestion from anesthesia. place a heating pad at the child's neck for comfort. administer analegesics analgesics to the child on a routine throughout the day and night. provide the child with ice cream when oral intake is initiated.

A nurse is collecting data for an adult client. identify the correct sequence of steps used for data collection of the abdomen.

inspection auscultate percussion palpate

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures he removed prior to surgery. Which of the following responses should the nurse make?

-" It's for your safety. Dentures can slip and block your airway during surgery." " You wouldn't want your teeth to be lost or broken during surgery, would you/" "The anesthesiologist requires everyone to remove their dentures." "what worries you about being without your teeth."

A nurse is reinforcing preoperative teaching with a client who is scheduled for arthroplasty in the next month and might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following suggestions should the nurse make.

-"Ask your provider to prescribe epoetin before the surgery." -You should take iron supplements prior to the surgery." -Request a family member donate blood for you.: -Donate autologous blood before the surgery,"

A nurse us reinforcing teaching with an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?

-"Drink a minimum of 1,000 milliliters of fluid daily." -"Increase your intake of refined-fiber foods." -"Sit on the toilet 30 minutes after eating a meal." -"Take a laxative every day to maintain regularly."

A nurse is reinforcing teaching with a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that teaching has been effective?

-"I should expect my heart rate to take longer to return to normal after exercise as I get older." -"urinary incontinence is something I will have to live with as I grow older." -" I can expect to have less ear wax as I get older." -My stomach will empty more quickly after meals as I grow older."

A nurse on a medical surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first?

-data collection for the client -plan of care for the client -nursing interventions performed for the client -evaluation of the client's progress.

A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?

obtaining hydrogen peroxide for the tracheostomy care. Obtaining cotton balls for the tracheostomy care. Obtaining a sterile glove for the tracheostomy care. Obtaining a sterile brush for the tracheotomy care.

A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process?

-identify goals for client care -obtain client information -document nursing care needs -Evaluate the effectiveness of care

A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?

-Tie the restraints to the side rails. -Perform range-of-motion exercises to the wursts every 3 hr. -Remove the restraints one at a time. (Remove the restraints one at a time) -Obtain a PRN prescription for the restraints

A nurse in an oncology clinic is collecting data for a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress?

-"My parents are retired, and they have come to help out with our children." "I am going to ask my husband to go to counseling with me." "I kept having nightmares about my upcoming surgery." -" My girlfriends bought me a nice wig."

A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?

-"tell me what I can do to help you overcome your fear of giving yourself injection." -I am sure your provider will not pleased that you refuse to give yourself insulin injections." -"It's okay. I'm sure your partner will be able to learn how to give you the insulin injections." -"You won't be able to go home unless you learn to give yourself insulin injections."

A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients' commitment to a long-term goal of weight loss.

-Attempt to increase the client's self-motivation. -keep detailed records of each client's progress. -Test client learning after each teaching session -Avoid discussing areas that might cause client anxiety.

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take?

-Auscultate for the blood pressure at the doornails pedis artery. -Measure the blood pressure with the client sitting on the side of the bed. -Place the cuff 7.6 cm (3 in) above the popliteal artery. -Place the bladder of the cuff over the posterior aspect of the thigh.

A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take?

-Change the topic because the client is trying to divert attention from the illness to the nurse. -encourage the client to express his thoughts about death and dying -tell the client that religious beliefs are a personal matter. -offer to contact the client' minister or the facility's chaplain.

A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying?

-Contact the family and ask them to stay with the client. -offer to call the client's minister -sit and hold the client's hand -leave the room and allow the client to cry privately.

A nurse is collecting data for a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first>

-Evaluate pedal pulses -Obtain a medical history -Measure vital signs -Ask the client if he is experiencing any pain in the leg.

A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first?

-Explain the x-ray procedure to the client -Help the client into a wheelchair before the transporter arrives -Ask if the client has any questions. -Identify the client using two identifiers.

A nurse at a screening clinic is collecting data for a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?

-Fifth intercostal space just medial to the midclavlcular line. -second intercostal space to the left of the sternum -Fifth intercostal space to the left of the sternum -second intercostal space to the right of the sternum

A nurse is collecting data for the health history of a client who is postoperative and has paralytic ileus. Which of the following findings should the nurse expect?

-Frequent bowel sounds with flatus -Absent bowel sounds with distention -Hyperactive bowel sounds with diarrhea -Normal bowel sounds with increased peristalsis

A nurse is collecting data from a client who reports abdominal pain. Further findings reveal the client has a temperature of 39.2 C (102.6F), a heart rate of 105/min, a soft contender abdomen, and menses overdue by 2 days, Which of the following findings should be the nurse's priority.

-Heart rate if 105 -Soft, contender, abdomen -temperature -overdue menses

A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from the stretcher to the bed?

-Luck the wheels of the bed and stretcher -Instruct the client to rise his arm above his head -elevate the stretcher 2.5 cm(1 in) above the height of the bed. -Log roll the client.

A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take?

-Measure the pulse using a Dropper ultrasound stethoscope -Check the client's pedal pulse -count the apical pulse rate for 1 full minute, and describe the rhythm in the chart. -take the pulse at each peripheral site and count the rate for 30 seconds.

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first>

-Open all sterile supplies and solutions -stabilize the tracheotomy tube -Don sterile gloves -Perform hand hygiene

A nurse is preparing to perform oral care for a client who is unresponsive. Which of the following actions should the nurse plan to take>

-Place the client supine -Keep both side rails up -Raise the level of the bed -Inspect the client's mouth using a finger sweep

A nurse is collecting data for a client who has had diarrhea and decreased urination for several days. Which of the following actions should the nurse take to determine if the client is dehydrated?

-Push on a fingernail bed until it blanches, released it, and observe how long it takes the skin to become pink. -Grasp a skin fold on the chest under the clavicle released it, and note whether it springs back -Press the skin in above the ankle for 5 seconds, release it, and note the depth of the impression. -Measure the skin fold thickness at the upper arm using a pair of calibrated skin fold calipers.

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use?

-Stand toward the client's stronger side -Instruct the client to lean backward from the hips -place the wheelchair at a 45 degrees angle to the bed (Positioning the wheelchair at 45 degrees angle allows the client to pivot, lessening the amount of rotation required.) -Assume a narrow stance with feet 15 cm (6 in) apart

A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room when the client states she no longer wants to have the surgery. Which of the following actions should the nurse take?

-Tell the client it is too late for her to change her mind because the surgery is already scheduled. -Telephone the operating room and cancel the surgery -Inform the client's family about the situation -Notify the provider about the client's decision.

A nurse is witnessing a client signing an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action?

-The client fully understands the provider's explanation of the procedure. -the client has been informed about the risks and benefits of the procedure -The nurse witnessed the provider's explanation of the procedure -The signature on the preparative consent form is the client's

A nurse is reinforcing teaching with a client who ha heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determine the client's ability to learn new dietary habbits?

-The involvement of the client in planning the change -The emphasis the provider places on the dietary changes -The learning theory the nurse uses to teach the dietary changes -The extent of the dietary changes planned for the client.

A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese Which of the following explanations should the nurse give the AP?

-The reading will be inaudible if the cuff is too small for the client." -"The width the cuff bladder should be 75 percent of the circumference of the client's arm." -"As long as the cuff will circle the arm the reading will be accurate.: -"Using a cuff that is too small will result in an inaccurately high reading."

A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take?

-Turn on the machine every 15 min to measure the client's blood pressure. -Record only blood pressure readings needed for the 15-min interval. -Obtain manual and automatic readings and compare them. -Disconnect the machine and measure the blood pressure manually every 15 min. (If the nurse questions the reliability of the monitoring equipment, a manual process should be used,. Also, malfunctioning equipment can pose a safety risk for the client, so it must be tagged and removed.)

A nurse is drawing blood for laboratory testing from a client that has results in a blood spill on her gloved hand. The client ha no documented bloodstream infection. Which of the following actions should the nurse take?

-Wash the gloved hands and then throw the gloves away. -Prepare an incident report to document the event. -carefully remove the gloves and follow with hand hygiene -Ask the provider to order a blood culture to determine the risk of infection

A nurse is auscultating the heart sounds of the client who has developed chest pain that worsens with inspiration. The nurse hears a high-pitched scratching sound with the diaphragm of the stethoscope placed at the third intercostal space of the left sternal border. Which of the following heart sounds should the nurse document?

-audible click -Murmur -Third heart sound -Pericardial friction rub

A nurse is assisting with planning a community campaign about seasonal influenza. Which of the following plans should be included as a secondary prevention stretegy?

-holding a community clinic to administer influenza immunizations -screening groups of older adults in nursing care facilities for early influenza manifestations -educating parents of young children about the dangers of influenza. -finding rehabilitation programs for older adults who have complications from influenza

A nurse is reinforcing teaching of postoperative deep breathing and coughing exercises with a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?

-the client asks the nurse to report the instructions before attempting the exercises -the client reports severe pain (asking the nurse to repeat the instructions demonstrates that, while the client might not totally understand the mechanics of performing the exercises, he does have a readiness to learn the activity.) -the client asks the nurse how often deep breathing should be done after surgery -the client tells the nurse that this exercise will probably be painful after surgery.