NSG100 Final

The nurse is providing care to a client who is experiencing constipating. The HCP rx Metamucil. What is the nursing consideration when administering this med to client?

offering sufficient water

A client is scheduled for a polysomnography​ (PSG) test. Which data should the nurse expect to be collected during this​ test? (Select all that​ apply.)

oxygen saturation heart rate leg movements eye movements

nurse is caring for pt dx with pneumonia. the nurse will include all of the following EXCEPT which in plan of care?

place client on fluid restriction of 500mL per day

A nurse is performing a nutritional assessment on a client. Which of the following findings could indicated malnutrition?

poor wound healing dry, brittle hair weak hand grip

A nurse is caring for a client who has hypertension. Which of the dietary patterns is sometimes followed by Asian clients and places clients at risk for this condition?

preparations of foods using sodium

laparoscopic appendectomy

primary intention wound care

"healing ridge is present"

proliferative stage

The nurse is reviewing the results of a urinalysis and notes that which of the following findings are considered abnormal?

protein 20mg/dL specific gravity 1.045 pH 4

Risk for loneliness r/t impaired verbal communication intervention

provide pt with writing board each shift

the nurse identifies the priority problem Ineffective Airway Clearance for the client dx with pneumonia. Which intervention can the nurse delegate to CNA?

remind pt to use incentive spirometer every 1-2hr when awake

nurse observes that pt's pulse ox is 89% what is priority nursing action?

reposition client

The nurse is assigned a PP client who had an anesthetic block during labor. When providing care for this client, which does the nurse anticipate?

residual urine

lder adult experiencing confusion, temp of 101.5, bruising to arms and legs, decreased urine output. The med dx is UTI. Most appropriate nursing dx:

risk for injury

The nurse recalls that a deficiency in Vitamin C can result in which of the following conditions?

scurvy

A nurse is discussing health problems associated with nutrient deficiencies with a group of clients. Which of the following conditions is associated with a deficiency of vitamin C?

scurvy bleeding gums

nurse is creating plan of care for an obese patient who is suffering from fatigue r/t ineffective breathing. Which intervention most effectively addresses short term goal?

sleeping on 2-3 pillows at night

An older client has constant dribbling of urine. The associated discomfort, odor, and embarrassment may support which nursing dx?

social isolation

Organism most commonly responsible for cellulitis

staph A

which intervention should the nurse implement for a client experiencing inadequate oxygenation?

suction airway if needed apply oxygen and assess the client's response prioritize and pace activities to prevent fatigue

pt who had a hip replacement yesterday has visual acuity of 20/200 after correction. what is nurse's best action to provide recreational activities during rehab phase

suggest use of talking books

What are never events?

surgical sponge left in incision, stage III and IV pressure ulcers, pulmonary embolisms after certain orthopedic procedures

Skin is intact with purple discoloration and a blood-filled blister.

suspected deep tissue injury

student nurse is administering barthel index on pt prior to discharge. the nurse will assess all of the following except

taking medication

a nurse is caring for pt who recently had stroke. having difficulty with communication and ADLs. what is the priority nursing action?

teach pt about special assistive devices

The nurse is providing care to a client who is experiencing urinary incontinence. Which independent nursing intervention is the most appropriate for this client?

teaching hygiene care

The most common source for bacteria that cause a UTI in all patients is

the perineal area

The nurse has received new medication orders for a client that has had a condition change. What components of the medication order should be present prior to administering the medication? Select all that apply.

the route by which the drug is to be administered the full name of the client the dosage of the drug the date and time when the order is written or placed in the order entry on the computer

A nurse is caring for a client who has impaired kidney function. For which process associated with pharmacokinetics should the nurse be most concerned when evaluating this client's response to an oral medication regimen?

Excretion

The nurse is caring for a group of medical surgical patients. Which patient is most at risk for getting an infection?

A patient who is recovering from a right total hip surgery

A nurse is providing care to a group of patients. Which patient will the nurse see first?

A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea

The nurse has recommended exercise to a client with a complaint of fatigue. The client​ states, "Exercising does not make sense when I am feeling so tired. All I want to do is just relax on the​ couch." Which response by the nurse provides the most accurate​ information?

"A mild to moderate exercise program has proven to be effective in reducing​ fatigue."

A nurse is caring for a client who has difficulty swallowing medications and is prescribed enteric-coated aspirin PO once daily. The client asks if the medication can be crushed to make it easier to swallow. Which of the following responses should the nurse provide?

"Crushing the medication might cause you to have a stomachache or indigestion."

A patient has sleep deprivation. After nursing interventions, which statement by the patient will indicate to the nurse that outcomes are being met?

"I feel rested when I wake up in the morning."

A nurse is providing information about pain control for a client who has acute pain following a subtotal gastric resection. Which of the following client statements indicates an understanding of pain control?

"I will call for pain medication before the previous dose wears off."

A nurse is teaching a patient about medications. Which statement from the patient indicates teaching is effective?

"I will rotate the sites in my left leg when I give my insulin."

The nurse conducts education for a client who is experiencing urinary incontinence. Which statement by the client indicates the need for further education?

"Incontinence is normal with aging."

An older adult client who has osteoporosis is discharged from the hospital. What does the nurse include in client teaching related to the client's home safety?

"Keep walkways free of clutter"

The nurse and a student nurse are discussing the effects of bed immobility on patients. The nurse knows that the student nurse understands the concept of mobility when making which statement?

"Patients with impaired bed mobility have an increased risk for pressure ulcers."

A nurse is giving an enteral medication. The patient asks why this method is preferable for this drug. How will the nurse reply?

"This route is safer, less expensive, and more convenient."

The nurse is assessing how a patient's pain is affecting mobility. Which assessment question is most appropriate?

"What activities, if any, has your pain prevented you from doing?"

A nurse is caring for a patient who recently had abdominal surgery and states they are experiencing severe pain. The patient's blood pressure is 110/60 mm Hg, and heart rate is 60 beats/min. Additionally, the patient does not appear to be in any distress. Which response by the nurse is most therapeutic?

"What would you like to try to alleviate your pain?"

A nurse at an extended-care facility is instructing a class of assistive personnel (AP) about client use of assistive devices during ambulation. Which of the following instructions should the nurse give the APs about the clients' use of a cane?

"When the client moves, he should move the cane forward first."

The nurse is teaching a student nurse about pain assessment scales. Which statement by the student indicates effective teaching?

"You cannot use a scale to compare the pain of my patient with the pain of your patient."

A nurse in a nutrition clinic is calculating BMI for several clients. The nurse should identify which of the following client BMIs as overweight? 24 30 27 32

27

Which statements accurately reflect the distinction between nursing dx and med dx:

1. A nursing diagnosis describes a pt's physical, sociocultural, psychological, and spiritual responses to an illness of health condition; a medical dx refers to disease processes. 2. A nursing dx changes as the client's responses to an illness or health situation change; a med dx remains the same as long as the disease process persists.

restraint should be removed, area massaged, and joints moved through full ROM every

2 hours

A nurse is discussing foods that are high in vitamin D with a client who is unable to be out in the sunlight. which of the following should be included in the teaching?

2 large, poached eggs

The nurse needs to move a patient up in bed using a drawsheet. The nurse has another nurse helping. In which order will the nurses perform the steps, beginning with the first one? 1. Grasp the drawsheet firmly near the patient. 2. Move the patient and drawsheet to the desired position. 3. Position one nurse at each side of the bed. 4. Place the drawsheet under the patient from shoulder to thigh. 5. Place your feet apart with a forward-backward stance. 6. Flex knees and hips and on count of three shift weight from the front to back leg.

3, 4, 1, 5, 6, 2

Newborn's skin is _______ thinner than an adult's skin at birth

40-60%

The nurse is providing care to a client who has been diagnosed with BPH. Which items in the client's health history indicate risk factors for this dx?

70 years of age african american

Which client requires isolation precautions?

73-year-old male with cough being ruled out for tuberculosis 54-year-old female with a fever who has been exposed to COVID-19

Which of the following vitamins are fat soluble?

A D E K

Which client is at greatest risk for developing an infection?

A 65 year old woman who had coronary bypass surgery 4 days ago

Which client should the nurse anticipate will have the greatest psychosocial needs?

A client in isolation

A nurse is caring for a client who has a new prescription for a drug. After receiving the first dose of the drug the client experiences anaphylaxis. Anaphylaxis represents which of the following results of the drug?

Adverse effect

A nurse is caring for a group of clients who have mobility issues. Which of the following clients is at the greatest risk for a complication?

An 80- year-old with a hip fracture.

A client with a common cold tells the nurse he is angry because the nurse practitioner would not give him any antibiotics. What would be the most appropriate response by the nurse?

Antibiotics have no effects on viruses

The nurse is caring for a patient to ease modifiable factors that contribute to pain. Which areas did the nurse focus on with this patient?

Anxiety and fear

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?

Ask the client to push her feet against the nurse's palms.

The nurse is caring for a patient who suddenly experiences chest pain. What is the nurse's first priority?

Ask the patient to rate and describe the pain.

The nurse is preparing to lift a patient. Which action will the nurse take first?

Assess weight and determine assistance needs.

A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions?

Atelectasis

Which of the following assessments is not considered to be an antropometric measurement?

BMR

The nurse is working on an orthopedic rehabilitation unit that requires lifting and positioning of patients. Which personal injury will the nurse be most at risk for?

Back

The public health nurse is providing community education aimed at promoting nutritional habits to decrease an individual's modifiable risk factors for heart disease such as obesity. Which topics should hte nurse include in the teaching session?

Benefits of consuming fruits and vegetables selecting lean protein sources preparing balanced meals strategies for mainting recommended daily caloric intake

A nurse is preparing to reposition a patient. Which task can the nurse delegate to the nursing assistive personnel?

Changing the patient's position

The nurse is teaching a child care class for mothers of young children. What should the nurse teach as being the most common mode of transmission of infection disease?

Children who don't wash their hands after using the bathroom

Which of the following statements best characterizes vitamin use?

Clients should be careful not to exceed recommended allowance for daily vitamin intake

A client having a routine physical​ states, "I​ don't understand why I am so tired—I only work​ 8-hour days sitting at my desk and rest when I get home. What can I do to increase my energy​ level?" Which intervention should the nurse select to address the​ client's feeling of​ fatigue?

Collaborate with the healthcare provider to implement a graded exercise program.

A nurse is evaluating care of an immobilized patient. Which action will the nurse take?

Compare the patient's actual outcomes with the outcomes in the care plan.

The nurse is providing teaching to the family of an older adult client with a UTI. Which common early symptom that is likely to occur more often in older adults should nurse stress?

Confusion

Which behavior indicates the nurse is using a team approach appropriately when caring for a patient who is experiencing alterations in mobility?

Consults physical therapy for strengthening exercises in the extremities

A nurse is admitting a client who has MRSA In a wound. Which of the following types of isolation precautions should the nurse initiate for this client?

Contact

A nurse is preparing to administer a drug to a client. In which of the following sections of a drug handbook should a nurse look to determine if the client can receive the drug?

Contraindications

The nurse is teaching a health class about the ChooseMyPlate program. Which guidelines will the nurse include in the teaching session?

Controlling portion sizes`

A nurse is providing teaching to an older adult client. The client asks, "Don't I need the same amount of nutrients that I did when I was younger?" Which of the following responses should the nurse make?

Old adults need an increased amount of calcium

Health promotion activities for improved sleep/wake cycles that you can include in health promotion plans include all of the following except:

Watching TV until you fall asleep

A nurse is completing a health history for a client diagnosed with narcolepsy. Which finding should a nurse anticipate when completing the assessment?

Excessive daytime sleepiness that results in sleep at an inappropriate time

A community health nurse is providing an educational session at the senior center on how to promote sleep. Which practices should the nurse recommend? (Select all that apply.)

Decrease fluids 2 to 4 hours before sleep. Use sedatives as a last resort. Get up if unable to fall asleep in 30 minutes.

A nurse is preparing a care plan for a patient who is immobile. Which psychosocial aspect will the nurse consider?

Depression

A nurse is preparing to transfer a client from a bed to a chair. Which of the following actions should the nurse take first?

Determine if the client can bear weight.

The nurse is having a conversation with an adolescent regarding the need for sleep. The adolescent states that it is common to stay up with friends several nights a week. Which action should the nurse take next?

Discuss with the adolescent sleep needs and the effects of excessive daytime sleepiness

You are completing a comprehensive assessment for a new patient at your clinic. Which is the best question to ask your patient to evaluate the efficacy of their sleep patterns?

Do you awaken feeling rested and refreshed?

The nurse is admitting a patient with an infectious disease process. Which question will be most appropriate for a nurse to ask about the patient susceptibility to this infectious process?

Do you have a chronic illness?

The nurse is assessing a new patient admitted to home health. Which questions will be most appropriate for the nurse to ask to determine the risk of infection?

Do you have a chronic illness? Have you traveled outside of the United States? Will you demonstrate how to wash your hands? Can you tell me what the signs and symptoms of infection are?

A pediatric client is admitted into the hospital for rubella. Which transmission based precautions should the nurse initiate?

Droplet

The nurse is caring for a pediatric client with whooping cough a.k.a. pertussis. Which precautions with the nurse begin?

Droplet

During a health assessment, a client states, "I only eat carbohydrates and low-fat foods. I don't understand why I am still gaingin weight!" Which principles of nutrition should guide the nurse's response?

Eating too many carbohydrates leads to excess glucose, which is converted to fat Excess carbohydrates can lead to obesity Carbohydrates should be high in fiber and low in sugar

A nurse is caring for a school aged child who injured the right leg after a bicycle accident. What signs and symptoms will the nurse assess for to determine if the child is experiencing a localized inflammatory response?

Edema, redness, and tenderness

A nurse in an urgent care center is caring for a client who experienced an ankle injury. Prior to examination by the provider, which of the following nursing actions should the nurse perform? (Select all that apply.)

Elevate the foot apply ice to the affected area apply a compression bandage

A client is receiving IV antibiotics for treatment of staphylococcus aureus infection. Which nursing interventions are appropriate when providing care to this client?

Encourage adequate fluid intake Monitor for allergic reaction Assess renal and liver function monitor vital signs

A patient needs assistance in eliminating an anesthetic gaseous medication (nitrous oxide). Which action will the nurse take?

Encourage the patient to cough and deep breathe

The nurse is preparing educational materials for a client with hypertension. Which of the following elements should hte nurse include when preparing this material?

Explaining the effects of sodium on blood pressure teaching the client how to read nutrition labels helping the client to recognize foods that are low in sodium showing the client how to follow a reduced sodium eating plan

A patient refuses medication. Which is the nurse's first action?

Explore with the patient reasons for not wanting to take the medication.

In teach mothers to be about infant nutrition, which instruction should the nurse provide?

Feed exclusively with breast milk or formula for the first 4-6 months

A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures?

Footboard

The nurse is preparing to insert a nasogastric tube in a patient who is semiconscious. To determine the length of the tube needed to be inserted, how should the nurse measure the tube?

From the tip of the nose ot the earlobe to the xiphoid process

The nurse is observing the way a patient walks. Which aspect is the nurse assessing?

Gait

A nurse is assisting an older adult client who sometimes loses her balance while walking. Which of the following devices should the nurse use when helping the client ambulate?

Gait belt

The nurse is monitoring a client who has been using NSAIDs for treatment of chronic back pain for several months. The nurse should instruct the client to take the medicine with food and a full glass of water to address which common side​ effect?

Gastric distress

Which statement about handwashing is in accordance with recommendations by the centers for disease control and prevention?

Handwashing must be done after contact with the client's intact skin, such as when taking a pulse.

The patient has been in bed for several days and now has an order for ambulation. Which action will the nurse take first?

Have the patient sit on the edge of the bed.

The nurse is gathering data on a patient. Which date or will the nurse report as objective data?

Heart rate of 94 bpm

The nurse is providing teaching to an immobilized patient with impaired skin integrity about diet. Which diet will the nurse recommend?

High Protein

A nurse is teaching a client who has left hemiparesis how to use a cane. Which of the following instructions should the nurse include?

Hold the cane on the right side to provide support for the weaker leg.

The nurse admits a client to the unit for a urinary tract disorder. Which questions are important for the nurse to include when assessing the client's voiding pattern?

How many times do you urinate in a 24h period? how often do you get out of bed at night to urinate? has your pattern of urination changed recently?

The nurse is caring for a client diagnosed with BPH, who is experiencing an increase in symptoms. Which statement by the client best explains source of the increased symptoms?

I am using an OTC cold medication

The nurse is describing the ChooseMyPlate program to a patient. Which statement from the patient indicates successful learning?

I can use this to make healthy lifestyle food choices

The client has been taught how to do Kegel exercises. Which statement by the client indicates a need for further information?

I will contract the muscles in my abdomen and thighs

Which statement accurately reflects that the client understands how to use the MyPlate plan?

I will eat foods from each of the five food groups at e every meal

A nurse is teaching a group of people about disease transmission. He knows that he needs to re-educate when one of the participants states which of the following?

If I don't feel sick, then I don't have to worry about transmitting diseases

The nurse is providing care to a client who ignore the urge to defecate while at work. The client states "i don't like to have a BM anywhere but at home." Which response by the nurse is most appropriate?

If you continue to ignore the urge to defecate, it can lead to problems

The nurse is caring for a patient who has a blood-borne pathogen. The nurse splashes blood above the glove to intact skin while discontinuing an IV infusion. Which steps with the nurse take next?

Immediately wash the site with soap and running water and seek guidance from the manager

A patient has a bacterial infection of a wound on their left lower leg. Which nursing diagnosis with a nurse add to the patient's care plan?

Impaired skin integrity

The nurse is caring for a patient with impaired physical mobility. Which potential complications of impaired mobility will the nurse monitor for in this patient? (Select all that apply.)

Impaired skin integrity Contractures Muscle atrophy

Which action should the nurse take to help the client with bowel and bladder dysfunction reduce the risk of infection?

Implement measures to prevent skin breakdown, provide hygienic care after episodes of incontinence, use standard precautions when handling linen after episodes of incontinence

Which question best helps the nurse establish a common cause of recurrent urinary tract infection in a preadolescent female client?

In what direction do you wipe after a bowel movement?

The nurse is providing nutrition education to a Korean patient using the five food groups. In doing so, what should be the focus of the teaching?

Including cultural practices with food preference of the patient

When administering medications to infants, it is important to remember which of the following? Select all that apply.

Infants are more sensitive to medications that act on the central nervous system (CNS). Infants have immature livers, which slow drug metabolism. Immaturity of renal function in infancy causes infants to excrete drugs less efficiently.

The student nurse is reviewing key terms for the concept of comfort and rest and reads "characterized by difficulty falling asleep or maintaining sleep or by a short sleep duration even with adequate time spent attempting to sleep". The student recognizes this as a definition for which of the following key terms?

Insomnia

The nurse is conducting a gait and posture assessment for a client who is experiencing mobility issues. Which action by the nurse is appropriate during this assessment?

Inspecting the client's spine for curvature

The nurse is caring for a patient who has cultured positive for Clostridium difficile. Which action will the nurse take when caring for this patient?

Instruct assistive personnel to use soap and water rather than sanitizer

The nurse is caring for a client with a history of UTI. Whch action by the nurse would decrease the risk of the client experiencing future UTIs?

Instruct the client to avoid delaying urination

The nurse is planning care for a client who is experiencing an alteration in mobility. Which would the nurse include as an independent nursing intervention?

Instructing on the importance of proper nutrition and an active lifestyle

The healthcare provider prescribes an indwelling urinary catheter for a client with urinary retention. Which intervention, along with strict aseptic technique, will decrease the risk of infection for this procedure?

Instructing the client to keep the urinary drainage bag below the level of the bladder

The nurse observes a nursing student prepare and administer medications to adult clients. Which action by the nursing student warrants intervention by the nurse?

Instructs the client to place a medication to be taken buccal under the client's tongue.

The nurse is educating a client and caregiver is about recurrent infections the client has experience. What priority intervention and the nurse include that as a first line of defense?

Intact skin and mucous membranes

A nurse is caring for a client with chronic UTI. The nurse is planning care for this client based on the priority nursing dx "urinary retention related to scarring." Based on this date, which treatment does the nurse anticipate from HCP?

Intermittent straight catheterization

The nurse administers medications by various routes by delivery. The nurse would use which route for a client who needs immediate effect of the medication?

Intravenous

When reviewing a list of drugs in a drug handbook, a nurse can identify the generic name of a drug in which of the following ways?

It begins with a lowercase letter.

Which statements regarding comfort are​ true? (Select all that​ apply.)

It can be associated with sleep and rest. It is subjective. It varies from one individual to another.

A breast-feeding mother of an infant with lactose intolerance asks the nurse about dietary measures. Which of the following foods should the nurse tell the mother are acceptable to consume while following a diet planned for lactose intolerance? Select all that apply.

Legumes Grilled Chicken Breast Green leafy vegetables

A nurse is concerned about a client's ability to metabolize a newly prescribed medication. Laboratory tests associated with which part of the body should the nurse monitor for functional performance because it is mainly associated with biotransformation of medication?

Liver

The patient who reports pain in the foot that moves up along the calf says: "My right foot feels like it is on fire." The patient reports that the pain started yesterday, and he or she has no prior history of injury or falls. Which components of pain assessment has the patient reported?

Location, quality, and onset.

The nurse is caring for a client who is 28 weeks pregnant. Which of the following postural changes can be caused by pregnancy?

Lordosis

The nurse is caring for two patients; both are having a hysterectomy. The first patient is having the hysterectomy after a complicated birth. The second patient has uterine cancer. What will most likely influence the experience of pain for these two patients?

Meaning of pain

The nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personel?

Measuring capillary blood glucose level

A patient receives a drug that has a narrow therapeutic range. The nurse administering the medication will expect to do what?

Monitor plasma drug levels.

A nurse is following safety principles to reduce the risk of needlestick injury. Which actions will the nurse take? Select all that apply.

Never force needles into the sharps disposal. Use needleless devices when possible. Use clearly marked sharps disposal containers.

After providing patient teaching on pain anatomy and physiology, the patient verbalizes understanding of the teaching when he identifies that the sensory receptors that respond to pain and send a signal along the sensory neurons to the spinal cord, where the signal is transmitted to the brain for interpretation are identified as:

Nociceptors

The nurse is caring for a client who is being discharged following abdominal surgery with an incision. Which instruction is most important for the nurse to teach this client regarding wound healing?

Notify the healthcare provider if you notice swelling warm for tenderness at the wound site.

The patient has a calculated body mass index (BMI) of 34. This would classify the patient as a. Unclassifiable. b. Normal weight. c. Overweight. d. Obese.

Obese

Which statement if made by the nursing student would indicate a need for further teaching when discussing malnutrition?

Obese patients can't experience malnutrition"

A nurse is making initial round on patients. Which intervention for a patient with poor wound healing should the nurse performed first?

Observe wound appearance and edges

The student nurse is reviewing common misconceptions of pain in infants and children. The student will identify all of the following as misconceptions except:

Parents are a valid source of information about their child's pain, especially for nonverbal children

A nurse delegates a position change to a nursing assistive personnel. The nurse instructs the NAP to place the patient in the lateral position. Which finding by the nurse indicates a correct outcome?

Patient is lying on their side.

The client complains of pain and asks the nurse for medication. Which intervention should the nurse perform first to aid in the decision to administer a PRN pain medication?

Perform a complete assessment of the client's pain.

A nurse is planning a 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 the service?

Performing hand hygiene

The nurse is caring for a patient who needs to be placed in the prone position. Which action will the nurse take?

Place pillow under the patient's abdomen after turning.

The nurse is working on a plan of care with her patient which includes turning and positioning and adequate nutrition to help the patient maintain intact skin integrity. The nurse helps the patient to realize that this breaks the chain of infection by eliminating which element?

Portal of entry

The supervising nurse is watching nurses prepare medications. Which action by one of the nurses will the supervising nurse stop immediately?

Prepares NPH insulin to be given intravenously (IV)

The nurse is assessing a client who is recovering following surgery. Which factor increases the client susceptibility to infection?

Presence of an incision

The nurse is caring for a​ 5-year-old client experiencing difficulty with sleeping. Which should the nurse discuss with the parents before creating a plan of care for this​ client?

Principles of good sleep hygiene

. Which interventions should the nurse implement for the client experiencing inadequate oxygenation? Select all that apply.

Prioritize and pace activities to prevent fatigue. Suction the airway if needed Apply oxygen and assess the client's response

The nurse has received a report from the emergency department that a patient with tuberculosis will be coming to the unit. Which items with the nurse need to care for this patient?

Private room, negative pressure airflow, N 95 respirator, Communication signs for airborne precautions

The nurse has received a report from the emergency department that a patient with influenza will be coming to the unit. Which items or the nurse need to care for this patient?

Private room, surgical mask, communication signs for a droplet precautions

The nurse is planning a teaching seminar for a group of young adult clients who are at risk for obesity. Which statement by the nurse best addresses their needs?

Proper diet and exercise programs can not only prevent obesity but also potentially improve the ability to think and the positivity of self-perception

Which of the following actions should the nurse take to promote sleep?

Provide bedtime rituals.

An older adult client has an inflamed area on a toe that is suspected of being infected. Which manifestation of infection should the nurse expect in this client? (select all that apply)

Purulent drainage fever inflammation erythema

The nurse closely monitors an older adult for signs of medication toxicity. Which physiological change is the reason for the nurse's action?

Reduced glomerular filtration

A woman is in labor and refuses to receive any sort of anesthesia medication. Which alternative treatment is best for this patient?

Relaxation techniques like guided imagery

The nurses exiting the room of a client who has Clostridium difficile infection. What actions with the nurse performed?

Removed gloves by securing the first gloves inside the second club, turn down inside out and roll it down into a bundle before discarding, wash hands with soap and water

The nurse is performing hand hygiene before assisting a healthcare provider with insertion of a chest tube. While washing hands thinners touches the sink which action with the nurse take next?

Repeat handwashing using antiseptic soap

A nurse finds an open vial of morphine lying on top of the cabinet in a client's room. Which of the following actions should the nurse take?

Report the discrepancy immediately.

A nurse is planning the discharge of a client who has sleep apnea and requires bi-level positive airway pressure (BiPAP) at night. The nurse should plan to consult with which of the following health care team members to help educate the client?

Respiratory therapist

The nurse is preparing to administer medications to two patients with the same last name. After the administration, the nurse realizes that they did not check the identification of the patient before administering medication. Which action should the nurse complete first?

Return to the room to check and assess the patient.

In order to provide the best intervention for patient, the nurse is often responsible for obtaining a sample of exudate for culture. What information will this provide?

What specific type of pathogen is causing an infection

The nurse is caring for a postpartum patient. The patient's labor has lasted over 28 hours within the hospital; the patient has not slept and is disoriented to date and time. Which nursing diagnosis will the nurse document in the patient's care plan?

Sleep deprivation

The nurse is preparing to admit a client that has been diagnosed with hepatitis C to the med surge unit. Which type of isolation precautions should the nurse implement with the care of this patient?

Standard

A client asks the nurse "is drinking a protein drink sufficient as a meal? Which is the nurse's most appropriate response?

Tell me more about the protein drink you are using

Which common clinical manifestation of infectious disease would cause the nurse concern?

Temperature 102°F

All of the following are modes of transmission except

The GI tract

The nurse is preparing to administer oral medications, what are some contraindications that would cause the nurse to question this route of administration? Select all that apply.

The client has a diagnosis of CVA and is NPO. The client has been nauseated and vomited three times this morning.

What is the definition of basal metabolic rate?

The cost of kilocalories of being alive

health environment. Which observation indicates the family member has a correct understanding of how to manage contaminated dressings?

The family member places the used dressings in a designated plastic bag.

The nurses observing a family member changing a dressing for a patient in the home health environment. Which observation indicates the family member has a correct understanding of how to manage contaminated dressings?

The family member places to use dressings in a designated plastic bag

The nurse is caring for a patient in the hospital. The nurse observes the nursing assistive personnel turning off the handle faucet with bare hands. Which professional practice principal or supports the need for follow up with the nursing assistive personnel?

The nurse is responsible for providing a safe environment for the patient

The nurse is caring for a hospitalized patient. Which behavior alerts the nurse to consider the need for a restraint?

The patient continues to remove the nasogastric tube.

The nurse is caring for a patient in the sleep lab. Which assessment finding indicates to the nurse that the patient is in stage 4 NREM?

The patient is difficult to awaken.

Which goal is most appropriate for a patient who has had a total hip replacement?

The patient will walk 100 feet using a walker by the time of discharge.

A nurse is educating a client about her risk factors for obesity. Which of the following statements made by the nurse is most appropriate when providing education about non-modifiable risk factors?

There has been evidence of a genetic predisopsition for developing obesity

The nurse is education a client about vegan options for increasing protein in the diet. Which of the following foods should hte nurse include in the education?

Tofu

A nurse is assessing the body alignment of a standing patient. Which finding will the nurse report as normal?

When observed laterally, the spinal curves align in a reversed "S" pattern.

The nurse is interviewing a client who is experiencing constipation. The client states "I don't understand what is going on. I feel the urge to use the bathroom, but once I am in there and I begin pushing with my abdominal muscles, nothing happens." Which is best response?

Try to avoid straining with abdominal muscles during defecation. Doing so may actually close the anal sphincter, preventing feces from passing through

A nurse is completing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Impaired skin integrity related to shearing forces?

Turn the patient every 2 hours, even hours.

The nurse is caring for a client who is exhibiting signs of systemic infection following surgery. Which diagnostic test with the nurse anticipate being ordered?

Urinalysis, White blood cell differential, white blood cell count, wound culture

The nurse is providing teaching to patient about UTIs in preschool children. The nurse should inform the parents that which of the following are common symptoms of UTI in this age groupe?

Urinary urgency Dysuria Fever

The nurse is caring for a patient on contact precautions. Which action will be most appropriate to prevent the spread of disease when caring for this patient?

Use a dedicated blood pressure cuff that stays in the room and is used for that patient only

The patient is unable to move self and needs to be pulled up in bed. What will the nurse do to make this procedure safe?

Use a friction-reducing device.

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

Use a gait belt to stand and pivot the client.

The nurse is teaching a class on infection control. Which measure is most important in breaking a link in the chain of infection?

Use personal Protective equipment (PPE)

The nurse is providing care to a client at a local clinic. The nurse suspects the client is experiencing UTI. Which urinalysis results support nurse suspicion?

WBC 10-15

The nurse has collected data related to the recent occurrence of several healthcare associated infections in the acute care facility. What nursing intervention should be implemented to decrease HAIs?

Wash hands before and after client care, encourage clients to receive vaccinations, cluster care of patients with similar conditions, select appropriate personal protective equipment for all isolation patients

The nurse is caring for a patient who becomes nauseated and vomits without warning. The nurse has contaminated hands. Which action should the nurse take next?

Wash hands with an antimicrobial soap and water

The nurse has withdrawn opioid pain medication into a syringe. When preparing to administer the medication, the client refuses, stating that pain is controlled currently at a level of 2 on a scale of 1 to 10. What is the appropriate nursing action?

Waste the medication with another nurse witness present.

The community nurse is educating a family about infection control measures. Which teaching will the nurse include?

Where personal protective equipment when appropriate, do not share drinking glasses with family members who are ill, keep the living environment as clean as possible

The nurse is caring for a patient who is at risk for infection. Which action by the nurse indicates correct understanding about standard precautions?

Where's I wear when emptying the urinary drainage bag

Nurse enters pt's room to eval response to IV pain med administered 20 min early. Nurse finds the client in the same position as when the med was administered. The nurse asked the pt to rate level of pain. pt states "I do not want to move."

Which aspects do these represent--Implementation, Evaluation, Assessment

A nurse is providing teaching to a client who has type 2 diabetes. the client states, "I eat pasta every day. I can't imagine giving it up." Which of the following responses should the nurse provide?

You don't have to give p pasta, just adjust the amount you eat

The nurse at a health fair is educating clients about risk factors associated with urinary incontinence. Which risk factors does the nurse include as nonmodifiable?

age

Factors that increase risk of falls

age 65+, reduced vision, history of falling, orthostatic hypotension, lower extremity weakness, gait and balance problems, urinary incontinence, improper use of walking aids, the effects of various meds (anticonvulsants, hypnotics, sedatives, certain analgesics)

the client is admitted to ER with facial trauma following MVA. Which should be the nurse's first action?

assess airway patency

Nurse is caring for a pt who suddenly bcomes agitated and confused. what action should the nurse take first?

assess oxygenation using pulse oximetry

which nursing intervention is most effective in preventing hospital acquired pneumonia in older adult patient?

assist patient to cough, turn, and deep breath frequently

nurse has included "ineffective airway clearance related to thick secretions" in the plan of care of a pt dx with pneumonia. which nursing intervention is most directed to resolution of the problem?

assist pt to perform effective coughing

nurse is caring for pt who experienced lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in lower lobes of both lungs. The nurse should recognize that this finding is most likely an indication of

atelectasis

pt 57yo is recovering in a hospital following mastectomy and breast reconstruction two days earlier. since her surgery, the client has been unwilling to mobilize despite the nurse's education on the benefits of early mobilization following surgery. the nurse would recognize that the client's prolonged immobility creates a risk for

atelectasis

nurse is caring for client who has MDD. basic ADLs

basic ADLs

A nurse is conducting a nutritional class on minerals and electrolytes. The nurse should include which of the following foods a s major source of calcium?

broccoli

A patient is on a low sodium diet. Whch food item choice by the patient will cause the nurse to intervene?

canned chicken noodle soup

a nurse explains the function of alveoli to a pt with respiratory problems. which info should the nurse share?

carries out gas exchange

A school nurse is teaching a group of adolescents abou healthy snack food choices. Which of the following foods should the nurse include?

carrot sticks with low-fat dip cheese and crackers unbuttered popcorn

what should the nurse do when physically assessing the quality of the client's oxygenation?

check symmetry of pt's chest observe breathing pattern and effort monitor the pt's respiratory rate

pt has indwelling catheter... reports urge to urinate. which of the following action should nurse take?

check to see if catheter is patent

Upon evaluation of a client's medical history, the nurse recognizes that which condition may lead to an inadequate supply of oxygen to the tissues of the body?

chronic anemia

During a home visit, the nurse is assessing an odler adult. Which assessment findings support the nursing dx "imbalanced nutrition, less than body requirements"?

client reports a problem with dentures slipping while chewing Client complains of occasional difficulty preparing food due to back pain Client is prescribed 15 medications Client's social security payments have gone down over the last year

Which statements accurately describe guideline for implementation

consult colleagues and the nursing and related literature to see if other approaches might be more successful; before implementing any nursing action, reassess the client to determine whether action is still needed

The community health nurse reviews data collected during interviews with community members during a health fair and decides to create a brochure on how to improve iron intake. which of the following action items might the nurse include that would help vegans and vegetarians increase their iron intake?

consume tofu consume lentils increase intake of vitamin C consume swiss chard

best description of the scope of the concept of functional ability

continuum from complete independence to complete dependence

high-pitched popping sounds, like milk poured over crisped rice cereal

crackles

A nurse is working in a community health center counseling an adolescent regarding a suspected eating disorder. The adolescent is of normal weight but admits to periods of overeating, especially when his parents fight. This client's eating habits best demonstrate which risk factor for obesity?

cultural and environmental factors

nurse is caring for pt with respiratory problems. which assessment finding indicates a late sign of hypoxia?

cyanosis

Risk factors that predispose pt to pressure ulcer development

decreased level of consciousness

this type of cognitive impairment can affect the patient's functional ability and is often caused by something physiological

delirium

Serum sodium levels not within normal limit-

dependent edema

A nurse is caring for a client from the Middle East who has celiac disease. Which ofthe following actions should the nurse perform regarding the client's diet?

determine the client's dietary preferences

The nurse is caring for an adult with a BMI of 26.8 who complains of sleep apnea and gout. The nurse anticipates that treatment of this patient for obesity will consist of which therapies?

diet exercise behavor modification

nurse needs to closely monitory o2 status of older adult patient who recently had anesthesia because of which age related change?

diminished respiratory muscle strenth may cause poor chest expansion

the nurse is caring for pt dx with community-acquired pneumonia who is having difficulty breathing. which intervention should nurse implement first?

elevate the head of the bead

which nursing action would be the highest priority when suctioning the client with a tracheostomy?

ensure adequate oxygenation before, during, and after suctioning

The nurse completes the health history with a client who is pregnant and works as a computer mainframe programmer. For which nonmodifiable risk factor is this client prone to experiencing​ fatigue?

female gender

A nurse is educating a group of clients who are pregnant about iron-rich foods. Which of the following foods should the nurse include?

fish lean red meats beans

Stage IV pressure ulcer-

full-thickness wound repair

Which of the following is not considered a barrier to nutrition?

government assistance programs

A nurse is caring for a patient who has been instructed to limit their dietary intake of vitamin K after being prescribed a new anticoagulant. Which food should the nurse instruct the client to limit?

green leafy vegetables

The client tells the nurse that he takes laxatives every day but is still constipated. The nurse's response is based on which reasoning?

habitual laxative use is the most common cause of chronic constipation

nurse is preparing to initiate bladder retraining program for client who has incontinence. which of the following actions should the nurse take?

have client record urination times remind client to hold urine until next scheduled urination time gradually increase urination intervals

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

healthcare-associated infection

Individuals of low socioeconomic status are at an increased risk for infection because of which of the following? (Select all that apply.) A) High cost of medications B) Inadequate nutrition C) Easy access to health screenings D) Uninsured or underinsured status

high cost of medication, inadequate nutrition, Uninsured or underinsured status

a nurse is caring for a client who suddenly begins to have respiratory difficulty. in what position would the nurse place the pt to facilitate respirations?

high fowler's

nurse is assessing aspects of functional ability for the pt in terms of social participation. The nurse will ask which of the following questions

how often do you have company? how often do you go out? what keeps you busy all day?

which statement most accurately describes why BPH is more common in older men than younger men?

hyperplasia of stromal and epithelial cells of the prostate gland occur over time

The nurse assesses a client and detects the following findings difficulty breathing, increased respiratory and pulse rates, pale skin with regions of cyanosis. what condition would the nurse suspect as causing these respiratory alterations?

hypoxia

Age-related changes in the veins and arteries put older adults at risk for diminished blood flow, which can contribute to

impaired skin integrity

Nurse is providing training for the clinical staff of a skilled care facility that primarily treats older adult clients. The nurse wants to include information on functional incontinence. Which risk factors of functional incontinence will the nurse include in the training?

impaired vision dementia lack of access to facilities limited mobility

nurse teaches pt about atelectasis. which statement by the pt indicates an understanding

important to to breathing exercises every hour to prevent atelectasis

The nurse conducts education for a client about urinary incontinence. Which statement by the client indicates the need for further education?

incontinence is normal with aging

The patient is asking the nurse about the best way to stay healthy. The nurse explains to the patient that from a nutritional point of view, the patient should (Select all that apply.) a. Maintain body weight in a healthy range. b. Increase physical activity. c. Increase intake of meat and other high-protein foods. d. Keep total fat intake to 10% or less. e. Choose and prepare foods with little salt.

increase physical activity maintain body weight in a health range choose foods that are unprocessed

The nurse is caring for pt receiving CBI after prostate surgery. Which nursing action is appropriate?

increase the irrigation flow rate until the return flow is pink and colorless

the nurse is caring for 5yo pt whose temp is 101.2F. nurse expects this pt to hyperventilate. Which factor does the nurse consider when planning care for this kind of hyperventilation?

increased metabolic demands

A nurse is administering pain medication to an 80-year-old man. What altered drug response might be expected due to the client's age?

increased possibility of drug toxicity due to higher drug plasma concentrations

The nurse educator is instructing staff members of an extended care facility on methods to decrease the risk for functional decline in their residents. The nurse educator will include all of the following except:

limiting physical activity

a nurse is preparing to administer a cleansing enema in an adult in prep for dx procedure. which of the following steps should the nurse take?

lubricate the rectal tube or enema tube warm the enema solution prior to instillation position client on left side with right leg flexed

upon entering the pt's room, all of the following would alert the nurse that the pt is having breathing difficulty except

lying flat in the bed

systemic failure

management decisions and organizational culture

The nurse is preparing to administer a topical medication to a patient with a large abrasion on the upper right extremity. If applied to the area of abrasion, the medication

may be absorbed more rapidly than if applied to intact skin.

the nursing student is learning the various causes of constipation. Which of the following is physiologic?

medication structural changes ie tumor

bariatric surgery is an option for which category or clients?

morbidly obese

nurse is caring for pt with COPD who is receiving 2L/min of O2. Which O2 delivery device is most appropriate for the nurse to administer the oxygen?

nasal cannula

In an agency with a culture of safety, when an error or patient safety issue is identified, the individual who reports the problem knows which information?

near misses are healthcare are used to improve care

decrease likelihood of fall at nighttime

nightlight

because of older adult's inability to concentrate urine as physiologic change, the nurse should assess for which condition

nocturia

nurse is preparing to suction a pt. Pulse is 65 and pulse ox is 94%. which finding will cause nurse to stop suctioning?

o2 sat 88%

nurse is assessing pt for adequacy of ventilation. what assessment findings would indicate the pt has good ventilation?

o2 sat 98% presence of quiet, effortless breath sounds at lung base bilaterally nail beds are pink with good capillary refill

Which statement if made by the nursing student would indicate a need for further teaching when discussing malnutrition?

obese patients can't experience malnutriiton?

The nurse is reviewing patients assigned to her care in terms of sleep and rest disorders. Which factors increase an​ individual's risk for experiencing obstructive sleep​ apnea? (Select all that​ apply.)

obesity smoking narrow airway

Which intervention for pt with poor wound healing should nurse perform first

observe wound edges

Incidence of lead poisoning is highest in

toddlerhood

The nurse receives rx to provide continuous bladder irrigation. Which catheter should the nurse choose?

triple lumen

Impaired skin integrity r/t shearing forces

turn pt every 2 hours

The nurse is providing care to client who is experiencing urinary retention. Which diagnostic tool does the nurse anticipate to be ordered for this client?

ultrasonic bladder scanner

Pt has pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as

unstageable

Client has Stage III pressure ulcer... eliminate shearing force by

using draw sheets to pull up, transfer, and position client.

nursing students are administering Barthel index to residents of an extended care facility. student recognizes that pt with greatest deficits

will have lower score on the index