Mod 1

Which of the following statements by a nursing student demonstrates an understanding of collaboration?

"Collaboration with patients has been used by nurses throughout the history of nursing."

A nurse is educating a preoperative client on how to cough effectively. What can the nurse tell the client to do to facilitate coughing?

"Hold a pillow or folded blanket over the incision."

The nurse educates an obese adolescent about healthy dietary habits and risk associated with obesity. Which statement by the adolescent indicates the need for further counseling?

"I should watch more TV to reduce the stress."

The nurse is completing preoperative teaching for a client, and it becomes apparent that the client does not understand the surgery that will be performed. What is the priority action for the nurse?

Notify the surgeon and document the finding.

When examining an adult client's preoperative laboratory results, the nurse notes that the potassium level is 2.9 mEq/mL. What is the nurse's priority action?

Notify the surgeon.

A client had surgical repair of a fractured ankle under local anesthesia and is being transferred from the postanesthesia care unit (PACU) to the surgical floor. Once admitted, what is the nurse's priority action?

Obtain a full set of vital signs

A client has been transferred to the postanesthesia care unit (PACU). Which action does the receiving nurse perform first?

Participate in a hand-off report.

A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical manifestations is associated with this diagnosis?

Positive Chvostek's sign

A client with type 1 diabetes mellitus has diabetic ketoacidosis. Which of the following findings has the greatest effect on fluid loss?

Rapid, deep, respirations

The nurse has just completed preoperative teaching with a client who will be having surgery the following day. Which statement by the client indicates that additional teaching is needed?

"I will go to the bathroom as soon as I receive all my preoperative medications."

Four clients are scheduled for surgery. Which client does the nurse determine is at highest risk for postsurgical complications?

89-year-old scheduled for a knee replacement

The nurse is providing education to a client regarding pain control post-operatively. What time does the nurse inform the client is the best time to request pain medication?

Before the pain becomes severe

What advice is appropriate for a growing child to prevent obesity? Select all that apply.

"You should eat small meals throughout the day." "You should drink fewer sweetened beverages every day." "You should watch television for less than 2 hours every day."

A client with diabetes asks the nurse why it is necessary to maintain blood glucose levels no lower than about 60 mg/dL. Which is the nurse's best response?

"Your brain needs a constant supply of glucose because it cannot store it."

A nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume deficit?

A client with vomiting and diarrhea

A client is taking furosemide (Lasix) and becomes confused. Which potassium level does the nurse correlate with this condition?

2.9 mEq/L

A client with preeclampsia is receiving magnesium sulfate to suppress or control seizures. Which nursing intervention should a nurse perform to determine the effectiveness of therapy?

Assess deep tendon reflexes

The nurse notes that the handgrip of the client with hypokalemia has diminished since the previous assessment one hour ago. Which intervention by the nurse is the priority?

Assess the client's respiratory rate, rhythm, and depth.

The nurse is caring for a client who had surgery 24 hours ago. He is alert and oriented when awakened and reports pain, but goes back to sleep when not being stimulated. He is on patient-controlled analgesia (PCA). What is the nurse's next action?

Assess the client's respiratory status.

When teaching the diabetic client about foot care, the nurse should instructor the client to do which of the following?

Avoid going barefoot.

A physician orders intravenously administered potassium for a child with hypertonic dehydration. A nurse performs which priority assessment before administering the potassium?

Checking the amount of urine output

Which client is at greatest risk for developing hypercalcemia?

Client with hyperparathyroidism

A time-out is performed before surgery. This includes which of the following?

Correct procedure Correct site Correct patient

A nurse mentor is explaining the benefits of collaborative practice to a nurse new to a facility. Which of the following research-based benefits is the nurse likely to identify as positive outcomes of collaboration? (Select all that apply.)

Decreased length of stay for patients Decreased staff resignations Increased job satisfaction of the staff

A client receiving preoperative medication tells the nurse that she took all the following vitamins and herbs last night before going to bed. Which one does the nurse report to the surgical team as a priority?

Garlic

A client had a gastric bypass procedure to treat morbid obesity. After surgery the client reports weakness, sweating, palpitations, and dizziness after eating. What should the nurse encourage the client to do?

Divide the daily caloric intake into six smaller meals

Which action is most appropriate during a preoperative chart review?

Ensure that the consent form is signed, dated, and witnessed.

A client is diagnosed with hypothyroidism. The nurse should assess the client for which of the following? Select all that apply

Heavy periods Constipation Weight gain of 10 pounds Decreased energy or fatigue

The management of a community hospital is trying to encourage a more collaborative environment among staff members. Which concept is most important for management to develop first?

Highlight that no single profession can meet the needs of all patients

The nurse understands fatigue, weakness, nausea/vomiting and dysrhythmias are signs of which problem?

Hypokalemia

A nurse mentor is explaining the benefits of collaborative practice to a nurse new to a facility. Which of the following research-based benefits is the nurse likely to identify as positive outcomes of collaboration? (Select all that apply.)

Increased job satisfaction of the staff Decreased staff resignations Decreased length of stay for patients

The nurse who is certified as a Critical Care Registered Nurse (CCRN™) represents the unit on the organizational performance improvement team. This is an example of which type of leadership?

Informal

The nurse is obtaining a health history from a client with diabetes mellitus who has been taking insulin for many years. Currently the client reports having periods of hypoglycemia followed by periods of hyperglycemia. The nurse should specifically ask if the client is doing which of the following?

Injecting insulin at the site of lipodystrophy.

A nurse working in a free clinic has recognized that health promotion for teenagers who are pregnant is needed. The nurse works to develop a team of health care experts in several disciplines from across the region to work toward improving the nutrition of pregnant teenagers. This is an example of what type of collaboration?

Interorganizational collaboration

The nurse is monitoring a client with hypoglycemia. Glucagon provides which function?

It prevents hypoglycemia by promoting release of glucose from liver storage sites.

The staff nurses complain the unit is disorganized and that there is no proper guidance from the nurse leader in regards to client services. Which type of leadership does the unit experience?

Laissez-faire

When conducting a health history with a female client with hyperthyroidism, the nurse should ask about which of the following changes in the menstrual cycle?

Light periods

A client who has undergone a thyroidectomy is subject to complication in the first 48 hours after surgery. The nurse should obtain and keep at the bedside equipment to:

Maintain an open airway

When a client's serum sodium level is 120 mEq/L, the priority nursing assessment is to monitor the status of which body system?

Neurological

A nurse has been asked to ensure informed consent for a surgical procedure. What might be a role of the nurse?

Signing the consent form as a witness

The nurse is completing a health assessment of a 42-year-old female with suspected Graves disease and hyperthyroidism. The nurse should assess the client for:

Tachycardia

A client has hyperthyroidism. After a thyroidectomy, the nurse teaches the client to:

Take thyroid replacement hormone for the remainder of the client's life.

A nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.4 mEq/L. Which of the following would the nurse expect to note on the electrocardiogram as a result of the laboratory value?

Tall peaked T waves

The nurse is assigned to a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for a fluid volume excess?

The client with renal failure

The clinical nurse leader needs to identify the staff who must go home due to low census. Which answer below describes a democratic style of decision making?

The clinical nurse leader asks the group if any of them would like the opportunity to go home and selects staff who volunteer.

The hospital must reduce the number of readmissions from 11% to 8% in the next year. Which of the following best represents the transformational leadership style in accomplishing this goal?

The director of quality develops a vision statement and action plan to achieve the goal. The director works directly with the involved departments to implement the action plan.

Which patient scenario describes the best example of professional collaboration?

The nurse and physician discuss the patient's muscle weakness and initiate a referral for physical therapy

Obesity in children is an ever-worsening problem. What concept should a nurse consider when caring for school-aged children who are obese?

There are familial influences on childhood eating habits.

Which laboratory finding does the nurse expect for a client with fluid volume deficit?

Urine specific gravity of 1.035

The nurse should teach the client with hyperthyroidism to prevent corneal irritation from mild exophthalmos by:

Wearing dark-colored glasses

The nurse is caring for a client who will be undergoing emergency surgery as soon as possible. Which information is most important for the nurse to teach the client at this time?

What to expect in the operating and recovery rooms