Nursing Concepts

A nurse is reinforcing teaching with a client who is prescribed buspirone (BuSpar). Which of the following statements by the client indicates an understanding of the teaching?

"I can have 1-2 alcoholic beverages a week"

A nurse working in a provider's office is reinforcing teaching with a client who is 36 weeks of gestation and has experienced a premature rupture of membranes. Which of the following statements by the client indicates a need for additional teaching?

"I will have my husband wear a condom during intercourse"

A nurse is working with the information technology department of the the facility to establish protocol regarding security mechanisms that will protect the electronic health records of clients period which of the following could result in a violation?

Ability of staff to access electronic health records of clients throughout the facility

Characterized by a shift or change in attitudes or beliefs

Affective learning

The use of intellectual skills to impart new knowledge to an individual

Cognitive learning

A nurse is making rounds on clients, who were assigned to a team of nurses, to determine if charting and client care was completed. This nurse is demonstrating which leadership role of the nurse?

Coordinator

A nurse is reinforcing teaching with the caregiver of a client who has aphasia. The nurse should include which of the following communication strategies in the teaching?

Cue client by providing cards that portray common needs

A nurse discovers that a client who is diagnosed with dementia received the wrong medication. Which of the following should the nurse his first action be?

Determine the clients condition

A nurse is caring for a neonate who was delivered at 30 weeks of gestation after his mother received two injections of betamethasone (Celestone). Because of the administration of betamethasone to the client's mother, the nurse should monitor the neonate for which of the following effects?

Hypoglycemia

A beginning student nurse is providing client-centered care for an adolescent who was admitted for tests to determine if he has type 1 diabetes mellitus. Which of the following statements by the student indicates a need for further teaching?

"I will keep my communication with the client to a minimum"

A nurse is reinforcing teaching about client consent to treatment with a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates a need for further teaching?

"It is the responsibility of the provider to obtain express consent"

A nurse working in a hospice facility is talking to a client's son who is distressed because his mother cries frequently and says she wants to die. Which of the following responses by the nurse is appropriate?

"Let's discuss some strategies you can use when this happens again"

A nurse on the coronary care unit is caring for a client who was transferred from the medical floor after experiencing a myocardial infraction. After the client is stabilized, she asks the nurse why she had been transferred to a unit where her family will be unable to stay with her all the time. Which of the following responses is appropriate?

"Let's talk for a minute about your concerns"

A nurse is reinforcing teaching about transdermal nitroglycerin (Nitro-Dur) to a client who has stable angina. Which of the following statements by the client indicates teaching has been effective?

"The patch should be effective within an hour of being applied"

An advanced student nurse assigned to clinical in a rehabilitation setting is preparing to participate in a team meeting. Which of the following statements by the student indicates a need for further teaching?

"The provider will not be at the meeting because she is not a member of the interdisciplinary team"

Compare and contrast accountability and responsibility

A sense of obligation and being dependable to complete all tasks inherent to the provision of nursing care is known as responsibility. Responsibility is also one of the components of accountability, which is being responsible and answerable for ones actions.

Web-based information should be evaluated for which of the following?

Accuracy, sponsorships, currency

A nurse is caring for a client who has osteoarthritis and is considering treatment with acupuncture. Which of the following is acceptable for the nurse to include in discussion with the client?

Acupuncture has been proven to reduce pain and increase function

A nurse is caring for a school-age child who is newly diagnosed with type 1 diabetes mellitus. Which of the following actions by the nurse is appropriate to prepare the child for administration of insulin?

Allow the child to manipulate the medical equipment

A charge nurse on the pediatric unit is making assignments for a nurse who has floated from the labor and delivery unit. Which of the following clients is appropriate for the charge nurse to assign?

An adolescent who is 2 days post operative following an appendectomy

A student is developing a plan of care for a client who has been diagnosed with cancer of the pancreas. Which of the following would be an appropriate resource to use in the development of an evidence-based plan of care?

CINAHL, MedlinePlus, OVID

A nurse is caring for an older adult who has an allergy to sulfa, is taking valproic acid (Depakote) for a seizure disorder, and has been newly diagnosed with osteoarthritis. The client states that keep seeing commercials on TV for Celebrex and want to try it period upon review of scientific evidence the nurse should inform the client which of the following?

Celecoxib is contraindicated in clients with an allergy to sulfonamide

A nurse is reinforcing teaching about performing suctioning to a client who is being discharged following a tracheostomy. Which of the following behaviors of the client indicates that teaching has been effective?

Demonstrating independent performance of the procedure

A nurse in a local Clinic is caring for a female client who is 35 years old. Which of the following screening should the nurse recommend to the client?

Dermatologist evaluation every three years to detect skin cancer

A nurse is caring for a client who has a urinary tract infection and is prescribed ciprofloxacin (Cipro). The client exhibits urticaria and angioedema following administration of the medication. Which of the following is the first action the nurse should take?

Determine respiratory status

A nurse is caring for a client who is diabetic and is being discharged home following an above-the-knee amputation. Which of the following health care professionals should be involved in the client's interdisciplinary team meeting?

Dietitian, physical therapist, social work

A nurse is caring for a client following a bronchoscopy. Which of the following findings requires immediate intervention?

Difficulty breathing

ABC

Directs the nurse to designate the client's top priority a compromised airway with the second priority being breathing, and the third priority being circulation

Safety & risk reduction

Directs the nurse to give priority to interventions that prevent a client from becoming injured

Survival potential

Directs the nurse to use a triage category system that labels clients in regard to those who are most severely injured but have a chance of living against those who are severely injured and have no chance of survival

Least restrictive

Directs the nurse to use the least restrictive or confining nursing intervention without risking harm to the client

A nurse is caring for a client who was admitted for acute alcohol delirium withdrawal 2 days ago. Which of the following findings is associated with this diagnosis?

Elevated temperature

A nurse is caring for a client who has an acid-base imbalance. For which of the following manifestations is metabolic alkalosis a possible complication?

Excessive vomiting

A nurse working in a provider's office is reinforcing teaching with a client who is 14 weeks of gestation. The nurse should instruct the client to immediately notify the provider if she experiences which of the following?

Facial edema

A nurse is reinforcing teaching to a client who has aphasia. Which of the following actions by the nurse is appropriate when communicating with the client?

Having the client use eye blinks to indicate yes or no

A nurse is reviewing the documentation of a newly licensed nurse. Which of the following actions by the newly licensed nurse while documenting requires a nurse perceptor to intervene?

Including in a client notes that an incident report was completed after a medication error

A nurse is reinforcing teaching about HIV with a group of high school students. Which of the following information is appropriate for the nurse to include?

Initial HIV symptoms are often similar to the flu

A nurse is caring for a client who had a cerebrovascular accident 2 days ago. Which of the following is the first sign of increased intracranial pressure (ICP)?

Lethargy

Which of the following are client attributes that impact safety?

Lifestyle choices, communication patterns, cognitive awareness

A nurse in a provider's office is orientating a newly licensed nurse on how to position a client in a vaginal examination. The nurse include in the teaching to place a client in which following position?

Lithotomy

A nurse is caring for a client who is diagnosed with active pulmonary tuberculosis is taking isoniazid (INH) and ethambutol (Myambutol). Which of the following manifestations reported by the client acetate the discontinuation of ethambutol?

Loss of color discrimination

The procedure of reviewing the standards that are followed in the delivery of care

Outcome Audit

A nurse at a long-term care facility is participating in a quality improvement project to reduce the occurrence of pressure ulcers. Which of the following audits should be conducted to determine the impact of a new skincare regimen on the incidence of pressure ulcers among clients who are immobile?

Outcome audit

Analysis of the actual result, or impact, of delivered care

PDSA Cycle

A nurse is caring for a child who has leukemia and is prescribed a transfusion of platelets. Which of the following should the client experience as a result of the transfusion?

Reduced bleeding time

Performed in response to a sentinel event by collecting and analyzing related data, and outlining corrective actions

Root cause analysis

A nurse is caring for a client who has nausea and prescription for promethazine (Phenergan) 25 mg IM. Which of the following is appropriate when preparing a medication for administration from an ampule?

Set ampule on a flat surface to withdraw the promethazine

A nurse is caring for a client who has a cerebrovascular accident and is having difficulty swallowing. Which of the following health care professional should attend the clients next interdisciplinary team needed to address the complications?

Speech pathologist

Evaluation or measurements of the impact environmental resources and influences have on the provision of care

Structure Audit

A nurse is caring for a child who is 24 hr postoperative following a supratentorial craniotomy. The nurse should maintain the child in which of the following positions?

Supine with head of the bed elevated to 30 degrees

A nurse has assigned four tasks to an assistive personnel (AP). Which of the following should the nurse instruct the AP to perform first?

Take an ABG specimen to laboratory

A nurse is caring for an adult client who has attempted suicide. The client tells the nurse he is calling his family to come pick him up. Which of the following actions by the nurse is appropriate when the client insists on leaving the facility against medical advice?

discuss risks associated with leaving

A nurse is caring for a client who has cancer. The client has decided to stop treatment and request a referral to hospice. They making the referral as requested the nurses illustrating which type of ethical principles?

Autonomy

Nursing process

Directs the nurse use the nursing process when prioritizing client care with assessment always being done before the other steps of the nursing process

A nurse is caring for a client who has been admitted to the medical unit with vomiting and possible dehydration which of the following findings requires immediate intervention?

Potassium 2.5 meq/L

Process of planning improvement strategies, implementation of those strategies, analyzing the impact of the strategies, and making changes to strategies as needed

Process Audit

A nurse is caring for an older adult client who was admitted 3 days ago with fractured ribs bilaterally and is suspected of being abused by his caregivers. Which of the following should be the nurse's priority goal?

Protect the client from further abuse

Integrates mental and physical activities in the acquisition of new skills

Psychomotor learning

A nurse is reinforcing teaching by demonstrating deep breathing and coughing exercises to a client who is scheduled for abdominal surgery. Which of the following responses by the client should the nurse postpone the teaching?

States that pain is an 8 on a scale of 0 to 10

A nurse is caring for a client who is receiving parenteral nutrition through a nontunneled central venous catheter and reports hearing a gurgling sound on the side of the catheter. The nurse suspects the catheter has migrated to the jugular vein. Which of the following actions should the nurse take first?

Stop the infusion