Midterm Exam NURS 203

A nurse is teaching a client how to administer medication through a jejunostomy tube (j-tube). Which of the following instructions should the nurse include?

"Flush the tube before and after each medication."

A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take.

1. Open the airway using the jaw-thrust maneuver, 2.determine effectiveness of the ventilator 3. Establish IV access 4.Perform a Glasgow Coma Scale (GCS) Assessment 5. Remove clothing for a thorough assessment

A nurse is preparing to administer hydromorphone 4 mg PO every 4 hr PRN for pain. Available is hydromorphone oral liquid 1mg/1mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do no use a trailing zero.) Number answer only

4

A nurse is performing a blood pressure screening for a client who has a family history of hypertension. Which of the following concepts is the nurse demonstrating?

Disease prevention

A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as a non-modifiable risk factor for developing a disease?

Genetics

A nurse is preparing to inject heparin subcutaneously for a client who is postoperative. Which of the following actions should the nurse take?"

Select a site on the client's abdomen.

A nurse is providing discharge instructions to a client who lives in subsidized housing and is concerned about being able to afford their medications. Which of the following factors should the nurse identify is affecting the client's health?

Socioeconomic

A graduate nurse who has been recently hired at a local hospital is completing an application for a nursing license. Which of the following information is a requirement for the nurse during the initial licensure process?

Substance misuse within the last 5 years

A nurse is teaching a client who has been newly diagnosed with diabetes mellitus. Which of the following information demonstrates health literacy by the client?

The client understands to take their blood glucose daily.

A nurse is planning to provide discharge teaching for a client who has hearing loss. Which of the following actions should the nurse plan to take?

Face the client while talking.

A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following should the nurse identify as an associated risk factor?

Family History

A nurse is teaching an adult client how to administer ear drops. Which of the following statements should the nurse identify as an indication that the client understands?

"I will gently apply pressure with my finger to the front part of my ear after putting in the drop."

A nurse is describing to another nurse how to use social media in client care. Which of the following examples should the nurse include as an acceptable social media?

Reviewing the use of a fitness application with a client is an acceptable use of social media. This can lead to an improvement in client outcomes and a healthier lifestyle.

A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client?

Pressure injury

A nurse is evaluating a client's understanding of the use of a sequential compression device (SCDs). Which of the following client statements indicates client understanding?

"This device will keep the blood pumping through my leg."

A nurse is preparing to administer methadone 2.5mg PO every 8hr. Available is methadone 5 mg tablets. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

0.5

A nurse is preparing to administer quinapril 40 mg PO daily. Available is quinapril 20 mg tablets. How many tablets should the nurse administer daily? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

2

Vital Signs 0800: BP 118/72 mm Hg Heart rate 82/min Respiratory rate 16/min Temperature 36.7° C (98° F) SaO2 98% on room air 1000: BP 128/82 mm Hg Heart rate 94/min Respiratory rate 18/min Temperature 36.7° C (98° F) SaO2 98% on room air Nurses' Notes 0745: Client awake and eating breakfast while watching the news on television. Client has hearing loss, does not wear hearing aid, and TV volume is loud. Rates pain as a 2 on a 0 to 10 pain scale. Incisional dressing dry and intact. 1000: Client ambulated in hallway with physical therapist. Client grimacing, appears upset, and is guarding incisional site. Reports pain a 5 on a 0 to 10 pain scale. Opioid analgesic administered. 1045: Client resting with eyes closed and listening to music with earphones. Reports feeling "very sleepy" after pain medication. Now rates pain as a 3 on a 0 to 10 pain scale. 1300: Ate 75% of lunch. Several visitors at bedside. Which of the following factors could present a barrier to the nurse effectively communicating with the client? (Select all that apply) 1. Family history of hearing loss 2. Numerous visitors in the client's room 3. Client's hearing deficit 4. Volume of the client's television

2,3,4

A nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia? (Select all that apply.) 1.Hypertension 2. Tachypnea 3. Bradycardia 4. Restlessness 5. Confusion

2,4,5

A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development. (Select all that apply.) 1. Place pillows under the client's knees and lower extremities 2. Assist the client to change positions often 3. Review laboratory values for total protein level 4. Instruct the client not to perform the Valsalva maneuver 5. Apply elastic stockings

2,5

Which of the follow statements is false?

2.2 kg = 2.2mL

A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain?

A client who has episodic back pain following a fall 2 years ago

A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?

A room with air exhaust directly to the outdoor environment

A nurse is obtaining informed consent from a client who is scheduled for a procedure. Which of the following roles is the nurse demonstrating?

Advocate

A nurse is caring for a client who has a prescription for a referral for case management services. Which of the following actions should the nurse identify is the responsibility of case management services?

Arrange for the client to receive home health care services

A nurse is documenting in a client's health record using the subjective, objective, assessment, and plan (SOAP) charting model. Which of the following information should be included in the subjective component?

Client reports chest pain after mowing lawn this morning

A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy?

Collaborating with providers to perform obesity screenings during routine office visits

A nurse is preparing an instructional session for a client about managing stress incontinence. Which of the following actions should the nurse take first when meeting with the client?

Determine what the client knows about stress incontinence

A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement?

Encourage the client to perform antiembolic exercises every 2 hrs

A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards?

Ensuring that health care providers comply with regulations

A nurse is observing a newly licensed nurse perform hand hygiene. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

Holds their hands below their elbows while rinsing off soap

A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?

Illness

A nurse is caring for a client who is placed on supplemental oxygen for hypoxia. The nurse should identify that which of the following findings indicate the intervention was effective?

Pink mucous membranes

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take?

Place a towel under the client's head.

A nurse is preparing a client for a colonoscopy. The client has a family history of colon cancer. Which of the following types of prevention is the nurse demonstrating?

Secondary

A nurse is providing teaching with a nursing colleague about sentinel events. Which of the following statements by the nursing colleague indicates an understanding?

"An example of a sentinel event is administering incompatible blood products to a client with harm noted."

A nurse is reviewing ethical principles with a nursing colleague. Which of the following statements by the nursing colleague indicates an understanding of ethical principles?

"Nonmaleficence is our nursing obligation to do no harm to our clients."

A nurse is preparing a presentation on heart health at a community center for a group of older adults. Which of the following actions should the nurse take to facilitate learning?

Articulate wording at a slow pace.

Which of the following is a true statement?

1 kg = 2.2lb

A nurse orienting a newly licensed nurse is reviewing the procedure for taking a telephone prescription. Which of the following statements should the nurse identify as an indication that the newly licensed nurse understands the process?

"Another nurse should listen to the phone call."

A nurse is providing preoperative education for a client who will undergo a mastectomy the next day. Which of the following statements should the nurse identify as an indication that the client is ready to learn?

"Can you tell me about how long the surgery will take?"

A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device?

"I should tell the nurse if the pain doesn't stop while I am using this device."

A charge nurse is instructing a newly hired nurse about the general guidelines of safety data sheets (SDS) within the facility. Which of the following statements should the charge nurse make? (Select all that apply) 1. "The SDS contains risks for chemical exposure." 2. "The SDS lists steps to take for chemical exposure." 3. "The SDS contains every chemical that is listed within the facility." 4. "The SDS contains the facility contact person if there is a chemical exposure."

1,2,3

A nurse is explaining the various types of health care coverage clients might have to a group of nurses. Which of the following health care financing mechanisms should the nurse include as federally funded? (Select all that apply.) 1. Exclusive provider organization (EPO) 2. Preferred provider organization (PPO) 3. Long-term care insurance 4. Medicare 5. Medicaid

4,5

A nurse in a clinic is caring for a client who is going to require 7 days of IV antibiotics and dressing changes for cellulitis. Which of the following care facilities should the nurse anticipate the client be admitted to?

Acute care hospital

A nurse is caring for a client who reports sneezing, productive cough, muscle aches, headache, and fever that has progressed over the last 4 days. Which of the following stages of infection is the client likely experiencing?

Acute illness

A nurse in a provider's office is collecting data from the caregiver of a 12-month-old infant who asks if the child is old enough for toilet training. Following an educational session with the nurse, the client agrees to postpone toilet training until the child is older. learning has occurred in which of the following domains?

Affective

A nurse is providing teaching to a newly licensed nurse about the purpose of documentation in the client's health record. Which of the following information should the nurse include?

Allows the nurse to document client care so that other team members involved in the client's care can be aware of client status.

A nurse looks up information in a client's medical record but is not involved in the care of the client. The nurse is violating which of the following standards of professional performance?

Code of ethics

A nurse is caring for a client who acquired a Staphylococcus aureus infection from touching a contaminated towel. Through which of the following modes of transmission did the client acquire the infection?

Indirect contact

A nurse is caring for a client who asks about healthy choices to lose weight. The nurse shares information from Healthy People 2030 to address the client's questions. Which of the following describes the Healthy People initiative?

It is a set of objectives for improving the health of American lives.

A nurse is preparing to transfer a client who has left-sided weakness from a sitting position in bed to a chair. Which of the following actions should the nurse take?

Lock the wheels on the client's bed.

A nurse is preparing an in-service about motivational interviewing for a group of staff nurses. Which of the following statements should the nurse make when discussing the OARS mnemonic?

O = Open ended questions should be utilized

A nurse is caring for a 4-year-old child who is resistant to taking medication. Which of the following strategies should the nurse use to elicit the child's cooperation?

Offer the child a choice of taking the medication with juice or water.

A nurse prepares an injection of morphine to administer to a client who reports pain, then asks a second nurse to give the injection because another assigned client needs to use a bedpan. Which of the following actions should the second nurse take?

Offer to assist the client who needs the bedpan.

A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as a modifiable risk factor for developing a disease?

Sunbathing

A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (Select all that apply.) 1. Remove the nasal cannula during mealtimes 2. Report any nausea or difficulty breathing 3. Apply petroleum jelly around and the inside the nares 4. Post "no smoking" signs in prominent locations. 5. Check the position of the cannula frequently

2,4,5

A nurse is preparing to reposition a client. Which of the following actions should the nurse take first?

Raise the height of the client's bed.

A nurse is obtaining an oxygen saturation on a client. Which of the following actions should the nurse take?

Choose a finger with a capillary refill less than 2 sec.

A nurse manager is providing education to a group of newly licensed nurses about various nursing organizations. Which of the following information should the nurse manager include?

The American Nurses Association's The Code of Ethics for Nurses with Interpretive Statements guides nurses through difficulty decisions

A nurse is observing a client drawing up and mixing insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place?

The client is able to demonstrate the appropriate technique

A nurse is caring for a client who has had a cough for 3 weeks and is beginning to cough up blood. The client has manifestations of which of the following conditions?

Tuberculosis

A nurse is evaluating ergonomic practice in the workplace. Which of the following should the nurse identify as an example of safe ergonomic practice?

Nurses are required to take breaks during a shift.

A nurse is instructing an assistive personnel (AP) about caring for a client who has a low platelet count. Which of the following instructions is the priority for measuring vital signs for this client?

"Do not measure the client's temperature rectally."

A nurse is teaching a client about medications at discharge. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I will eat two crackers with the pain pills."

A nurse is teaching about values to a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding related to client-centered care?

"It is important that the nurse is aware of the client's values."

Client is admitted with a 3-day history of abdominal cramps and diarrhea. Client reports 4 to 5 liquid stools/day. Client was taking amoxicillin/clavulanate for a respiratory tract infection, 500 mg PO q 12 hr for 10 days. Antibiotics completed 7 days ago. Abdomen soft, nondistended with hyperactive bowel sounds audible in 4 quadrants. Stool contains mucous and is foul-smelling. Stool sent for culture Laboratory Results 1400: Stool culture positive for Clostridium difficile (negative) A nurse is caring for the client. Which of the following actions should the nurse take? Select all that apply. 1.Place the client in a private room. 2. Wear a protective gown while caring for the client. 3.Place a mask on the client when they leave their room. 4.Place the client in a negative pressure room. 5. Wear an N-95 respirator while caring for the client.

1, 2

A nurse is caring for a client who has Parkinson's disease and needs assistance with ADLs. Which of the following referrals should the nurse anticipate the provider to prescribe? (Select all that apply) 1. Occupational Therapy 2.Physical Therapy 3.Dietician 4.Social worker

1,2,3

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? (Select all that apply.) 1. Use surgical asepsis to remove and clean the inner cannula 2. Clean the outer cannula surfaces in a circular motion from the stoma site outward 3.Apply oxygen source loosely if the SpO2 decreases during the procedure 4. Cut a slit in gauze squares to place beneath the tube holder 5.Replace the tracheostomy ties with new ties

1,2,3

A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? (Select all that apply.) 1. hold the cane on the right side 2. after advancing the cane, move the weaker leg forward 3. keep two points of support on the floor 4. place the cane 38 cm (15in) in front of the feet before advancing 5. advance the stronger leg so that it aligns evenly with the cane

1,2,3

A nurse is caring for a client in the emergency department who has a oral body temperature of 38.3 C (101F), pulse rate 114/min, and respiratory rate 22/min. The client is restless with warm skin. Which of the following interventions should the nurse take? (Select all that apply) 1.Obtain culture specimens before initiating antimicrobials 2.Assist the client with oral hygiene frequently 3. Allow the client to shiver to dispel excess heat 4. Encourage the client to rest and limit activity 5. Restrict the client's oral fluid intake

1,2,4

A nurse is caring for a client who has severe acute respiratory syndrome (SARS). The nurse knows that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply) 1. Planning and evaluating control and prevention strategies 2. Determining public health priorities 3. Identifying impact on local grocery stores 4. Monitoring for common-source outbreaks 5. Ensuring proper medical treatment

1,2,4,5

A charge nurse is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. Which of the following are manifestations of a systemic infection? (Select all that apply) 1. Increase in pulse and respiratory rate 2. Fever 3. Edema 4. Pain or tenderness 5. Malaise

1,2,5

A nurse is preparing to perform endotracheal suctioning for a client. The nurse should follow which of the following guidelines? (Select all that apply) 1. Apply suction while withdrawing the catheter 2. Use a new catheter for each suctioning attempt 3. Perform suctioning on a routine basis every 2-3 hours 4. Maintain medical asepsis during suctioning 5. apply suction for 10 - 15 seconds

1,2,5

A nurse is preparing to renew their nursing license. Which of the following information is required to submit to the Board of Nursing? 1. Substance misuse in last 5 years 2. Travel abroad 3. History of criminal record 4. Disciplinary actions taken against license

1,3,4

A nurse is reviewing a client's prescribed medications at the beginning of the day shift. Which of the following 0900 medications can be given anytime between 0700 and 1100? (Select all that apply) 1.A subcutaneous injection prescribed once weekly 2. A blood pressure pill prescribed twice daily 3.An antibiotic prescribed every 8 hrs 4. A once-daily multivitamin 5. Eye drops prescribed every 3 hrs

1,4

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include? (Select all that apply) 1. Place a surgical mask on the client if transportation to another department is unavoidable 2. Patient does not require private room. 3. Use sterile gloves when handling soiled linens 4. Wear a gown when performing care that might result in contamination from secretions. 5. Wear a mask when providing care within 3 ft of the client

1,4,5

A nurse is preparing to administer potassium chloride 15 mEq PO every 12 hr. Available is potassium chloride liquid 20 mEq/15mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do no use a trailing zero.) Number answer only

11.3

A nurse is performing an admission assessment on a client. The nurse determines the client's radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client's pulse deficit? (Numerical answer only)

16

When reviewing the role of a change agent, which of the following examples should a nurse identify as part of this role? (Select all that apply) 1. Maintain client privacy. 2. Ensure medications are administered on time. 3. Provide safe care to clients. 4. Introduce the latest form of a medication for cardiac clients. 5. Provide information on a newly developed insulin pump.

2,4,5

A nurse is instructing a group of assistive personnel in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply) 1. Count the rate for 30 sec if it is irregular 2. Have the client rest an arm across the abdomen 3. Observe one full respiratory cycle before counting the rate 4. Place the client in semi-Fowler's position 5. Count and report any sighs the client demonstrates

3,4,5

A nurse is monitoring a client for adverse effects following the administration of an opioid. Which of the following effects should the nurse identify as an adverse effect of opioids? (Select all that apply) 1.Urinary incontinence 2. Diarrhea 3. Nausea 4. Orthostatic hypotension 5. Bradypnea

3,4,5

A nurse is preparing to administer fluoxetine 35mg PO daily. Available is fluoxetine solution 20mg/5mL. Who many mL should the nurse administer daily? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) Number Answer Only

8.8

A nurse is teaching a newly licensed nurse about a nonrebreather (NRB) oxygen mask. Which of the following instructions should the nurse include?

A nonrebreather mask should fit snugly over a client's face.

A nurse is measuring the blood pressure of a client who has a fractured femur. The blood pressure reading is 140/94 mm Hg, and the client denies any history of hypertension. Which of the following actions should the nurse take first?

Ask the client if they are having pain

A nurse is evaluating how well a client learned the information presented in an instructional session for a client about managing stress incontinence. Which of the following actions should the nurse take first when meeting with the client?

Ask the client to explain how to select or prepare meals

A nurse is caring for a client how is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority?

Assist the client to high fowler's position

A nurse is caring for a client who is scheduled for an elective surgery. The client informs the nurse that they no longer wish to proceed with surgery. Which of the following ethical principles should the nurse uphold for the client?

Autonomy

A nurse is instructing a client who has heart disease about ways to improve their health such as eating a heart healthy diet. Which of the following concepts is the nurse demonstrating to the client?

Health promotion

A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (Select all that apply)

Home health care Skilled nursing facilities Rehabilitation facilities

A nurse is reviewing the five levels of communication. Which of the following statements should the nurse identify as describing emotional communication?

It refers to the speaker's state of emotions when sending a message.

A nurse is providing change-of-shift report to another nurse for a client using the Introduction, Situation, Background, Assessment and Recommendation (ISBARR) communication tool. Which of the following information should the nurse include as part of the situation component of this communication tool?

Medical condition

A nurse is reviewing a client's medical record. Which of the following findings should the nurse identify as a fall risk?

Multiple sclerosis

A nurse is collecting data from a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the client's pain?

Offer the client a pain scale to measure their pain.

A nurse is evaluating the documentation of a newly licensed nurse. The nurse should identify that which of the following entries requires intervention?

Prescription received for MSO4 4.0 mg PRN pain

A nurse at a clinic is collecting data about pain from of a client who reports severe abdominal pain. The nurse asks the client if there has been any accompanying nausea and vomiting. Which of the following pain characteristics is the nurse attempting to determine?

Presence of associated manifestations

A nurse who completed their shift realized they forgot to take a client's vital signs as frequently as prescribed. Which of the following actions should the nurse take to uphold the American Nurses Association's Code of Ethics for Nurses with Interpretive Statements?

Report this omission to the charge nurse and the nurse on the next shift.

A nurse reviewing a client's health record notes a new prescription for lisinopril 10 mg PO once every day. The nurse should identify this as which of the following types of prescriptions?

Routine dose

A nurse is preparing to complete an occurrence report for a client who fell at the facility. Which of the following actions should the nurse take?

Use objective terminology when documenting

A nurse is preparing an in-service about communication for a group of staff nurses. Which of the following techniques should the nurse include when discussing therapeutic communication?

Using silence