Nursing Concepts Beginning Test

A nurse on the coronary care unit is caring for a client who was transferred from the medical floor after experiencing a myocardial infarction. After the client is stabilized, she asks the nurse why she had to be 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." indicates teaching has been effective. Upon application of the patch, the medication becomes effective within 20 to 60 min and lasts until the patch is removed.

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

Ability of staff to access electronic health records of clients throughout the facility The ability of staff to access electronic health records of clients throughout the facility allows for viewing confidential information on clients the staff might not directly be involved in the care of. The majority of staff should only be allowed to access the electronic health records of clients on the unit where he or she works.

A nurse is caring for a client who had 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. Acupuncture has been proven to reduce pain and increase function among clients who have osteoarthritis through clinical research studies. Clinical research has also shown additional benefits of acupuncture, such as improving memory and orientation among clients who have certain types of dementia.

A nurse is caring for a client who has cancer. The client has decided to stop treatment and requests a referral to hospice. By making the referral as requested, the nurse is illustrating which of the following ethical principles?

Autonomy

A nurse is caring for an older adult client 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, "I keep seeing commercials on TV for Celebrex and I want to try it and see if it will help my pain." Upon review of scientific evidence, the nurse should inform the client of which of the following?

Celecoxib is contraindicated in clients with an allergy to sulfonamide. Celecoxib (Celebrex) is a nonsteroidal anti-inflammatory, cyclooxygenase-2 (COX-2) inhibitor, which is indicated to relieve some manifestations caused by rheumatoid arthritis and osteoarthritis in adults. Celecoxib contains a sulfa molecule; therefore, celecoxib is contraindicated in clients who have an allergy to sulfa.

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

Demonstrating independent performance of the procedure demonstration is the best evaluation tool for psychomotor learning, which is the acquisition of knowledge or skills that integrate mental and muscular activity.

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

Dermatologist evaluation every 3 years to detect skin cancer A mammogram every year is not an appropriate screening to recommend to a 35-year-old client. Women ages 40 or older should have annual mammograms. A colonoscopy every 10 years is not an appropriate screening to recommend to a 35-year-old client. Men and women ages 50 and older should have a colonoscopy every 10 years.

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

Determine the client's condition This is the first action the nurse should take when discovering a medication error. The client is the immediate concern, and determining his condition is crucial to the delivery of safe, effective care.

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

Difficulty breathing

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 the nurse preceptor to intervene?

Including in a client's nurses' note that an incident report was completed after a medication error The content of this question emphasizes the concept of professionalism through the recognition of documentation requirements. Professionalism incorporates legal and ethical principles, as well as compliance with the standards of nursing practice in the provision of safe, quality nursing care that exhibits both accountable and responsible behavior. This is not an appropriate action and requires intervention from the nurse preceptor. Incident reports are completed for incidents that are considered to be a deviation from expected outcomes of routine care and are often used in quality improvement programs for the facility. While an incident report should be completed for a medication error, this report is not referred to, nor does it become part of, the client's permanent record.

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 in a provider's office is orienting a newly licensed nurse on how to position a client for a vaginal examination. The nurse should include in the teaching to place the client in which of the following positions?

Lithotomy

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

Loss of color discrimination

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 (hypokalemia) his finding requires immediate intervention. A potassium level of 2.5 mEq/L is below the expected reference range. Hypokalemia can lead to arrhythmias or cardiac arrest. Because this level is life threatening, it is the priority at this time.

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. Maslow's Hierarchy of Needs states that if there is not a physiological need, then safety needs must be considered first. Because the client has been hospitalized for 3 days, physiological needs have most likely been taken care of; therefore, the nurse should act to keep the client safe from harm.

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

Set the ampule on a flat surface to withdraw the promethazine. the ampule can be set on a flat surface or held upside down, tilted at a slight angle. After the ampule is broken, the rim is considered contaminated and should not be touched with the needle.

A nurse is caring for a client who had a cerebrovascular accident and is having difficulty swallowing. Which of the following health care professionals should attend the client's next interdisciplinary team meeting to address this complication?

Speech pathologist A speech pathologist identifies clients at risk for aspiration and develops recommendations for therapy. The speech pathologist should attend the next meeting to address difficulty swallowing in a client who has had a cerebrovascular accident. An occupational therapist works with clients who have limited functional abilities to develop skills that are necessary to complete activities of daily living. A social worker offers education and counseling to clients and families to provide links to community resources, plan for discharge, or resolve conflict A respiratory therapist provides specialized therapy to clients who have respiratory difficulties, such as oxygen therapy, inhalation therapy, administering pulmonary function tests, collection of sputum specimens, and collection of arterial and venous blood specimens.

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

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