NURS 370

A nurse manager is evaluating the time-management strategies of a newly licensed nurse on the pediatric unit. Which of the following actions taken by the nurse are effective time-management strategies? A. Completing one task before beginning another tasks B. Documenting client care at the end of the shift C. Taking time to plan care at the beginning of the shift D. Completing more time-consuming tasks at the end of the shift E. Mentally visualizing a procedure prior to gathering equipment

A, C, E

A public health nurse is assisting community leaders to develop a disaster response in the event of an outbreak of a serious communicable disease. When teaching the community leaders about infectious disease, the nurse should explain that a vector is which of the following? A. A mode of transmission for the disease B. A microorganism that causes the infection C. An environment where the pathogen can survive D. A client who is susceptible to the infection

A.

A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status? A. Daily weight B. Blood pressure C. Specific gravity D. Intake and output

A. -According to the evidence-based-priority-setting framework, daily weight provides important information about the client's fluid status

A nurse is planning a smoking cessation program for women of childbearing age. Which of the following risks is associated with smoking during pregnancy? A. Infant developmental delays B. Maternal osteoporosis C. Maternal ulcers D. Infant lung cancer

A. -Increased risk of developmental delays, premature birth, low birth weight, SIDS, bronchitis, and pneumonia

A nurse is teaching a client about the use of a straight-legged cane. Which of the following client actions indicates an understanding of the teaching? A. The client holds the cane on the unaffected side B. The client walks by stepping with the unaffected leg before the affected leg C. The client holds the cane directly next to the foot D. The client holds the cane with a straight elbow

A. -Provides a wide base of support and stability

A nurse is screening a client who has an S-shaped spinal column with unequal shoulder heights. The nurse should identify these findings as manifestations of which of the following abnormalities? A. Scoliosis B. Lordosis C. Torticollis D. Kyphosis

A. -S-shaped or C-shaped spinal column and uneven shoulder or hip heights

A nurse is performing a community assessment in a rural setting. Which of the types of health care is most likely to be absent in this setting? A. Tertiary care B. Primary prevention C. Chronic care D. Secondary prevention

A. -Specialized care through consultation, usually obtained after referral from a primary care provider

A client in a long-term care facility falls out of bed, fracturing his left hip. The side rails on the bed were not raised at bedtime, although the client was identified to be at risk of falling. Which of the following torts has occurred? A. Negligence B. Battery C. Intentional tort D. Slander

A. -Occurs when a client is exposed to an unreasonable risk of injury

A charge nurse in an ED receives notification of a massive explosion at a local industrial plant. More than 30 casualties from the explosion will begin arriving shortly. Which of the following actions should the nurse take first? A. Activate the emergency response plan B. Call in available personnel C. Obtain additional supplies D. Move current clients to hospital rooms

A. -The greatest risk to the incoming clients is further injury due to delayed assessment and intervention

A nurse receives the morning change-of-shift report and delegates several tasks to an assistive personnel (AP) on the team. Which of the following tasks should the nurse instruct the AP to perform first? A. Obtain the morning capillary blood glucose test B. Bathe a client scheduled for physical therapy at 0900 C. Distribute the breakfast trays D. Fill pitchers with fresh water and ice

A. -The nurse should apply the urgent vs. non-urgent priority-setting framework when delegating tasks

A nurse is caring for an older adult client who dies during the night while his partner is at his side. the next morning the partner says, "I can't believe he's gone." Which of the following responses should the nurse make? A. "It must be hard to accept that this has happened" B. "His suffering is over now, and he is in a better place" C. "Would you like to take his personal items home with you?" D. "He lived a long and full life"

A. -This is a therapeutic response because the nurse is restating what the client has said, which allows the partner to hear what the nurse received from their communication

A charge nurse is planning an in-service training session about client advocacy with a group of staff nurse. Which of the following situations should the nurse include as an example of client advocacy? A. Discussing treatment options with a client who was diagnosed with pancreatic cancer B. Notifying the provider when a client has questions about procedure C. Helping a client make a list of questions to ask the provider D. Clarifying the dosage of a medication prescribed for a client who has impaired liver function E. Carrying out the end-of-life wishes outlined in the living will of an older adult client who has end-stage renal disease

B, C, D, E -As a client advocate, the nurse should make sure clients have all their questions answer and possess the information needed to make an informed decision

A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration A. Redness at the infusion site B. Edema at the infusion site C. Warmth at the infusion site D. Oozing of blood at the infusion site

B. -Edema do the fluid entering subcutaneous tissue is an indication of infiltration

A nurse is assessing a client who reports nausea and vomiting for 2 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit? A. Decreased urine specific gravity B. Increased heart rate C. Decreased hematocrit D. Increased skin turgor

B. -Indicates to the nurse that the client is experiencing fluid volume deficit. Other findings can include an increased BUN level, dry mucous membranes, and dark yellow urine

A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client's death is imminent? A. Urinary retention B. Cold extremities C. Hypertension D. Tachycardia

B. -First in feet and then in the hands

A nurse is preparing to teach the health care team about the concept of critical pathways. Which of the following statements about the purpose of a critical pathway should the nurse plan to include? A. "A critical pathway is a plan of care specific to the nursing interventions necessary for client care" B. "A critical pathway is a tool that legally binds the health care facility to provide services as outlined" C. "A critical pathway is a multidisciplinary took that guides client care and base outcomes on an externally imposed timeline" D. "A critical pathway is a plan that may be the same for several similar diagnoses"

C. -

A nurse is assisting with the informed consent process for a client who is scheduled for a below-the-knee amputation. The client asks the nurse, "Why are they making me have this surgery today? I don't understand why they are doing this." Which of the following actions should the nurse take? A. Complete an incident report B. Administer an anti-anxiety medication C. Notify the provider of the client's comments D. Answer the client's questions and verify understanding

C. -It's the nurse's responsibility to notify the provider if the client has questions or appears not to understand the procedure. The provider is responsible for providing clarification

A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements made by the client indicates she is experiencing psychological distress? A. "My parents are retired, and they have come to help with our children" B. "I am going to ask my husband to go to counseling with me" C. "I keep having nightmares about my upcoming surgery" D. "My girlfriends bought me a nice wig"

C. -Manifestations of anxiety and PTSD

A nurse is administering an IM injection to a 5-month-old infant. Which of the following injection sites should the nurse use? A. Deltoid B. Ventrogluteal C. Vastus lateralis D. Dorsogluteal

C. -The nurse should use the vastus lateralis site over the anterior thigh for IM injections for infants and children

Based on recommendations following a regulatory agency visit, the nurse manager mandates a policy change. One of the staff nurses on the unit is resistant to the change, and the nurse manager notes that this nurse does not deliver care according to the new policy. Which of the following actions should the nurse manager take? A. Explain the disciplinary consequences of refusing to implement the new policy B. Reinforce with the staff nurse the importance of implementing the policy change C. Ignore the staff nurse's resistance and allow peer pressure to facilitate the change D. Encourage the staff nurse to verbalize reasons for resisting the change

D. -A meeting between the nurse manager and staff nurse will provide an open forum for the staff nurse to verbalize the reasons for reluctance in adopting the new policy

A nurse is reviewing laboratory results for a client who is at 12 weeks gestation. Which of the following findings should the nurse report to the provider? A. Hgb 12g/dL B. WBC 15,000/mm^3 C. Fasting blood glucose 80 mg/dL D. Serum creatine 0.4 mg/dL

D. -Below the expected reference range for a client who is pregnant

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? A. Tenderness when touched B. Pink, shiny tissue with a granular appearance C. Serosanguineous drainage D. Halo of erythema on the surrounding skin

D. -Erythema (redness) on the surrounding skin might indicate underlying infection (purulent drainage, swelling, warmth, or strong odor should be reported, too)

A nurse is caring for a client who has a prescription for acetaminophen 325 mg PO for an oral temperature above 38.4 degrees Celsius. Above what Fahrenheit temperature should the nurse administer acetaminophen to the client?

101.1

A nurse is preparing to administer 40 mL of a 0.9% sodium chloride IV to infuse over 20 minutes. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?

30 gtt/min

A nurse is preparing to administer a feeding via a gastronomy tube to a client who had a stroke. Which of the following actions should the nurse take prior to initiating the feeding? A. Warm the feeding in a microwave oven B. Elevate the head of the client's bed C. Flush the tube with 0.9% sodium chloride for irrigation D. Verify that the client's gastric pH is above 4

B. -Clients who have a brain injury cannot protect their airway from aspiration

A nurse is preparing to insert an NG tube for a client who requires enteral feedings. Which of the following instructions should the nurse give the client before beginning the procedure? A. "Inhale forcefully during insertion" B. "Raise your index finger if you need to pause during the insertion" C. "Bear down during insertion" D. "Avoid making any swallowing motions during the insertion"

B. -Instruct the client that the insertion of an NG tube is uncomfortable and the gag reflex will be activated during the procedure

A nurse caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take? A. Change the topic because the client is trying to divert attention from the illness B. Encourage the client to express thoughts about death and dying C. Tell the client that religious beliefs are a personal matter D. Offer to contact the client's minister or the facility's chaplain

B. -This is the therapeutic technique of reflecting. Depending on the situation, the nurse can also share some thoughts on this topic

A community health nurse is preparing a disaster preparedness plan for smallpox. Which of the following groups of people should the nurse include for inoculation in the plan? A. Newborns B.. Mortuary workers C. Immunosuppressed clients D. Clients who have eczema

B. -smallpox is an extremely contagious, disfiguring, and deadly disease caused by the variola virus. The nurse should plan to provide prophylaxis through immunization to mortuary workers, who have a high risk of exposure to smallpox

A nurse is cleaning a client's wound by swabbing from the area of least contamination to an area of greater contamination. Which of the following rationales should the nurse identify for using this technique? A. Preventing the transfer of microorganisms to the nurse B. Keeping microorganisms from entering the wound C. Applying minimal pressure to the wound D. Keeping excess moisture from entering the wound

B. -Starting at the area of least contamination and working toward the area of greatest contamination prevents the spread of microorganisms within the wound

A nurse is administering medications to a client who is recovering from a stroke and has right-sided paralysis. The nurse places the client's medications on the left side of the mouth and administers pills one at a time. Which of the following ethical principles is the nurse displaying? A. Autonomy B. Nonmaleficence C. Fidelity D. Justice

B. -The duty to do no harm and to protect clients from harm by eliminating threats

A nurse is caring for a client who has major depressive disorder. The client tells the nurse, "Don't bother me. Find someone else to talk with. I don't have anything to say that's worth sharing." Which of the following statements should the nurse make? A. "Surely you can't think I don't want to talk to you." B. "I would like to sit quietly with you for a while." C. "I'm assigned to take care of you, so I intend to spend time with you." D. "Let's talk about what you would like for lunch today."

B. -This is a therapeutic response because the nurse is offering availability, which lets the client know that the nurse has a desire to understand

A nurse is teaching a client who is postoperative about the importance of turning, coughing, and breathing deeply. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "If I do this often, I won't experience muscle wasting" B. "If I do this often, I won't get pneumonia" C. "If I do this often, I won't get constipation" D. "If I do this often, I won't have a fast heartbeat"

B. -Turning, coughing, and breathing deeply help prevent respiratory complications such as pneumonia by promoting lung expansion and secretion removal

A nurses performing an admission assessment for a client. Which of the following responses by the nurse reflects the communication technique of clarifying? A. "Now that we have talked about your medications, let's talk about your pain" B. "Are you having other symptoms?" C. "It sounds like your pain is intermittent" D. "It seems as though you have really had a rough time these past few weeks"

C. -A was focusing -B was asking relevant questions D was empathy

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use? A. Stand toward the client's stronger side B. Instruct the client to lean backward from the hips C. Place the wheelchair at a 45-degree angle to the bed D. Assume a narrow stance with the feet 15 cm (6 in) apart

C. -Allows the client to pivot, lessening the amount of rotation required

A nurse is assisting a client who is eating at mealtime. Suddenly, the client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first? A. Place an oxygen mask on the client B. Check the client's pulse C. Determine whether the client is able to breathe D. Wrap arms around the client from behind

C. -Nursing process priority-setting framework; ABCs

A nurse is reviewing the use of side rails with an assistive personnel (AP). Which of the following statements by the AP indicated further teaching is required? A. "I should not leave all 4 side rails up unless there is a prescription for restraints" B. "An alert client will be safest if I raise the 2 upper rails at the head of the bed" C. "If the client seems confused, I'll raise all 4 side rails so that he doesn't hurt himself" D. "If a client is sedated, I should raise all 4 side rails to prevent a fall out of bed"

C. -Raising all 4 side rails can put the client at a greater risk for injury

The charge nurse overhears a nurse informing other unit nurses that the charge nurse is giving preferential treatment to the unit nurses on the night shift. Which of the following approaches by the charge nurse reflects an assertive response to resolve this conflict? A. Understanding that the unit nurse is misinformed and taking no action B. Assigning the unit nurse to work the night shift to facilitate direct experience with the night shift C. Meeting one-on-one with the unit nurse to discuss these concerns D. Confronting the unit nurse during the next meeting regarding this statement

C. -Schedule a time to speak privately with the unit nurse about the situation. Assertive behavior involves discussing a situation directly with the person involved

A nurse is caring for a client who asks if the client in the next room is in pair because she cries out frequently. Which of the following statements should the nurse make? A. "That client has cancer and is quite uncomfortable" B. "We are doing our best to keep that client as comfortable as possible" C. "Does the crying out bother you?" D. "Why don't you ask that client's family when they visit?"

C. -This therapeutic response focuses on the client's feelings rather than on the confidential information concerning the client in the next room

The adult child of a client arrives to take his parent hoe from the facility following a colon resection. The client's son tells the nurse, "I don't know how I am going to take care of my mom now." Which of the following responses should the nurse make? A. "A home health nurse will be stopping by tomorrow. If you have any questions, you can ask the nurse" B. "Your mother has been taught to care for the colostomy independently" C. "What part of your mother's care are you concerned about?" D. "Your job is quite simple. I'll make sure that the colostomy bag is clean before your mother leaves"

C. -This therapeutic response uses clarification to address the son's immediate concerns

A nurse is caring for a client who is hospitalized and has a new tracheostomy. Which of the following actions should the nurse take when performing tracheostomy care for the client? A. Perform tracheostomy care using medical asepsis B. Allow enough slack under the tracheostomy ties to insert three fingers C. Soak the inner cannula of the tracheostomy tube in normal saline D. Cut a sterile gauze pad to place between the neck and tracheostomy tube

C. -To loosen secretions

A nurse in a same-day procedure unit is caring for several clients who are undergoing different types of procedures. The nurse should anticipate that the client with which of the following devices can safely undergo magnetic resonance imaging (MRI)? A. Coronary artery stents B. Aneurysm clip C. Hearing aids D. Automated internal defibrillator

C. -Can be removed

A nurse that a coworker may be in an impaired state when providing care to clients. Which of the following actions should the nurse take? A. Ask other coworkers if they feel the same way B. Speak directly with the impaired coworker C. Report these observations to the nurse manager D. Refuse to work with the impaired coworker

C. -If the coworker is found to be impaired, this action will initiate an appropriate intervention and support, and clients will be protected from the actions of an impaired coworker

A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family-centered care? A. "Social services can contact various community resources that will be helpful." B. "I will review the care plan to make the necessary changes." C. "Let's set up a meeting time with the doctor to discuss your options for home care." D. "I will make a list of things we need to do before discharge."

C. -In family-centered care, the nurse considers the health of the family as a unit; therefore a client and family members help determine their outcomes and goals

A nurse is providing teaching to a client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein? A. Eggs B. Soybeans C. Lentils D. Yogurt

C. -Incomplete proteins are missing one or more of the essential amino acids necessary for the synthesis of protein in the body. Lentils, vegetables, grains, nuts, and seeds

A nurse is inserting an NG tube into a client who begins to cough and gag. Which of the following actions should the nurse take? A. Remove the NG tube B. Advance the NG tube quickly C. Pull the NG tube back slightly D. Ask the client to tilt his head backward

C. -Instruct the client to breathe slowly. Once the client relaxes, gently advance the tube as the client swallows

A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client? A. Speak directly into the client's impaired ear B. Exaggerate lip movements C. Speak loudly D. Face the client when speaking

D. -Stand or sit at the same level to maximize communication. Many clients who are hearing-impaired combine lip reading with their residual hearing when communicating

A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes a yellow, thick, drainage on the dressing. The nurse should document this finding as which of following types of drainage? A. Sanguineous exudate B. Serous exudate C. Serosanguineous exudate D. Purulent exudate

D. -Thick yellow, green, or brown drainage, usually indicates wound sloughing or infection

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse provide? A. "It's for your safety. Dentures can slip and block your airway during surgery" B. "You wouldn't want your teeth to be lost or broken during surgery, would you?" C. "The anesthesiologist requires all clients to remove their dentures" D. "What worries you about being without your teeth?"

D. -Validates the client's feelings of agitation and seeks a reason

An RN and a LPN are caring for a client who has a small bowel obstruction and is NPA with an NG tube set to continuous suction. Which of the following tasks should the RN perform? A. Obtain daily weight B. Inspect the client's oral cavity for dryness hourly C. Measure and record the NG tube output every 4 hours D. Assess for bowel sounds every 2 hours

D. -Only the RN is qualified to evaluate the sounds and qualify them as hypoactive, normal, or hyperactive

A nurse is preparing to administer an afternoon dose of ampicillin to a client. The client appears upset and refuses to take the medication before throwing the pill on the floor. Which of the following entries should the nurse enter into the client's medical record? A. The client refused to take medication B. The client stated, "I will not take this pill." C. The client seemed angry and hostile D. The client threw the medication on the floor

D. -The nurse should document exactly what took place for an accurate, factual account of the events. The nurse should document the client's actions in the medical record