Nursing exam 1

The nurse is preparing a nursing care plan. Which actions would most likely prevent errors in interpretation when making a nursing diagnosis? Select all that apply. Accurate interpretation of cues Using reliable cues Failure to consider conflicting cues Using an insufficient number of cues Consider cultural influences or developmental stage

accurate interpretation reliable cures cultural considerations

Which communication technique conveys the nurse's interest in a patient's needs and problems? Showing approval Listening actively Comparing patient experiences Engaging in excessive self-disclosure

actively listening

A 35-year-old athlete becomes aggressive when he is not allowed to be ambulatory due to a fractured leg. He tries to get out of the bed unattended and falls. What therapeutic communication techniques should the nurse apply in attending to the client Listen actively. Share empathy. Give personal opinions. Ask relevant questions. Confront the client. Leave the room if the client is shouting.

actively listening sharing empathy relavent questions

A febrile client diagnosed with pancreatitis complains of pain in the abdomen. Following an initial interview and the assessment, the nurse prepares a nursing care plan. Which diagnoses are actual nursing diagnoses? Select all that apply. Acute pain Ineffective thermoregulation Risk of imbalanced fluid volume Risk of imbalanced nutrition Readiness for enhanced family coping

acute pain and ineffective thermoregulations ***current human response

Which interventions does the nurse perform while caring for a patient with tuberculosis? Select all that apply. Instruct the patient to wear a fit-tested-N95 respirator Place the patient in an airborne infection isolation room Avoid serving fresh raw fruit or vegetables to the patient Ensure that sterile objects touch only other sterile objects Perform hand hygiene before and after touching the patient

airborne isolation only sterile times touch other sterile items no fresh or raw fruit hand hygiene

The nurse is teaching the patients in a nursing home about good oral hygiene practices. What is the purpose of oral hygiene? Select all that apply. Provides patient comfort. Removes tartar, plaque, and food particles from, around, and between teeth. Prevents infection and irritation of teeth and the oral cavity. Decreases halitosis.

all of the above

The nurse is assessing a preschool child in a hospital setting. Which interventions will the nurse implement for assessing the child effectively? Select all that apply. Communicate with the child during the assessment. Examine the child's head, eye, throat, and nose first. Allow the child to play with toys during the assessment. Examine the child alone in the absence of parents or siblings. Permit the child to keep the underpants on until the genital examination.

allow them to play with toys allow underpants on communicate

What are the nursing responsibilities during the transfer of a patient from the hospital to the rehabilitation facility? Select all that apply. Allow the health care team to access electronic patient information. Consult with health care professionals and refer the patient to the facility. Delegate patient care planning to unlicensed assistive personnel. Instruct the family to coordinate with the interdisciplinary health care team. Collaborate with pharmacists, primary care providers, and family caregivers.

allowing health care team to access electron patient information consult with health care professionals and refer patient to rehab center

Which of the following activities does the nurse delegate to nursing assistive personnel in regard to crutch walking? Notify nurse if client reports pain before, during, or after exercise. Notify nurse of client complaints of increased fatigue, dizziness, light-headedness when obtaining vital signs before and/or after exercise. Notify nurse of vital sign values. Evaluate the client's ability to use crutches properly. Prepare the client for exercise by assisting in dressing and putting on shoes.

answers are all correct except evaluation

A nurse is explaining the elements of professional communication to nursing students. The nurse states that being self-directed and independent is essential for accomplishing goals. Which element of communication is the nurse referring to? Empathy Autonomy Courtesy Assertiveness

autonomy

a client reports nausea, has little interest in eating, and has increased salivation. How does the nurse relieve nausea in the client? Administer antiemetics Avoid sudden position changes Provide a comfortable environment Provide oral care every 2 hours Promote excessive intake of oral fluids

avoid sudden position changes comfortable environment oral care ever 2 hours

A nurse is teaching juniors about the health promotion model (HPM). What are the components that belong to the health promotion model? Behavioral outcomes Individual characteristics and experiences Behavior-specific knowledge and affect Individual's perception of susceptibility to illness Likelihood that a person will take preventive action

behavioral outcomes individual characteristics and experiences behavior specific knowledge and affect

Order the following informatics tasks based on how they are applied to enhance the nursing process.

capture data organize data analyze info nursing diagnosis patient care plan

order of preparing catheter

check PCP and patient plan care gather supploes hand hygiene identify patient supplies at bedside table appropriate vein insert catheter

A nurse reviews data gathered regarding a client's pain symptoms. The nurse compares the defining characteristics for acute pain with those for chronic pain and in the end selects acute pain as the correct diagnosis. This is an example of the nurse avoiding an error in: Data collection. Data clustering. Data interpretation. Making a diagnostic statement.

data interpretation

The nurse has formulated several nursing diagnoses following an assessment of a client. Which statements are correctly written nursing diagnoses? Select all that apply. Diarrhea related to food intolerance Impaired physical mobility related to musculoskeletal injury Pain related to difficulty in ambulation Ineffective breathing pattern related to pain in the chest Anxiety related to diagnostic procedure

diarrhea related to food intolerance impaired physical mobility related to muskosleket infecting breathing related to pain in chest

Which is an evaluative measure used in the nursing process? Determine if the nursing education meets the standards of care. Determine if the test and reference drug have similar bioavailability. Determine if the incidence and prevalence of new diseases are recorded. Determine if nursing care was effective and patients met the expected outcomes.

effective and outcomes met

internal communication factors

empathy liking others ability to listen

The nurse is implementing wound care for a patient. The nurse introduces self and explains the procedure of wound care to the patient. The nurse then performs hand hygiene and checks the patient's treatment plan. Which specific intervention facilitates the patient's cooperation with wound care? Introducing self Performing hand hygiene Checking the care plan of the patient Explaining the wound care procedure

explaining

A patient with a hearing impairment prefers lip reading while communicating. Which actions by the nurse would be helpful in making communication during this interview effective? Select all that apply. The nurse speaks loudly. The nurse faces the patient. The nurse uses hand gestures. The nurse emphasizes the lip movements. The nurse ensures good lighting in the room.

face the patient use hand gestures good lighting

What symptoms indicate ineffective coping in the patient with stress? Select all that apply. Reporting fatigue and lack of sleep Expressing a need for social support Displaying increasing feelings of anxiety Exhibiting a negative attitude towards recovery Expressing difficulty in making decisions

fatigue and lack of sleep increased anxiety negative attitude

steps of nasogastric tube

hand hygiene clamp and disconnect the NG to prevent contamination flush NG tube with normal saline aspiration revmoves the instilled saline reconnect the ng tube

feeding tube steps

hand hygiene final step is comparing the strip with the color chart from the maufacture

adolescent assesments

head to to privacy give constant feedback

What information should the nurse obtain from the patient's health history while assessing the cognitive status of that patient? Dietary habits Exercise habits Educational levels Current medication Current health problems

health problems medications education

the senior nurse is teaching a group of nursing students about using the technique of summarizing in therapeutic communication. Which advantages should the nurse teach? Select all that apply. Summarizing helps recall previous discussions. Summarizing helps participants to focus on key issues. Summarizing helps reveal true personal experiences. Summarizing is useful in the terminal phases of the client relationship. Summarizing brings a sense of caring and human connection.

helps recall discussion helps focus on key ideas terminal phase

An adult patient has a body temperature of 98.6° F (37° C), shallow breathing with a respiratory rate of 16 breaths/minute (BPM), excessive cough, and blood pressure of 142/100 mm Hg. What does the nurse infer about the patient's condition? The patient has hypertension and bradypnea. The patient has hypotension and ineffective airway clearance. The patient has hypotension and normal body temperature. The patient has hypertension and ineffective airway clearance.

hypertension and bradypnea

In the following examples, which nurses are making nursing diagnostic errors? A nurse uses an incorrect diagnostic label. A nurse considers a patient's cultural background when reviewing cues. A nurse listens to lungs for first time and is not sure if abnormal lung sounds are present. After reviewing objective data, a nurse selects a diagnosis of fear before asking patient to discuss her feelings. A nurse prepares to complete decision on diagnosis and realizes that clinical criteria are grouped incorrectly to form a pattern.

incorrect label not sure of abnormal lung sounds selects diagnosis on fear prepares clinical created in incorrect group

A patient has increased blood pressure. Which factors could be responsible for this finding in the patient? Select all that apply. Increased blood volume Decreased cardiac output Decreased blood viscosity Increased vasoconstriction Increased elasticity of vessel walls

increased blood volume increased vasoconstriction

order of nursing assessment

inspection palpation percussion auscultation

While dressing a wound, the nurse finds that a patient has uncontrolled wound drainage. Which interventions should the nurse perform in order to extend further care to the patient? Use a fit-tested-N95 respirator Perform hand hygiene prior to wearing gloves Transfer the patient to a reverse ventilation room Mark "Isolation Precautions Required" on the chart Apply gloves and a gown when touching the patient

isolation precautions required hand hygien gloves

A nurse is teaching a group of student nurses about the three levels of prevention. What are the activities included in the secondary prevention of diseases? Use of specific immunizations Use of environmental sanitation Individual and mass screening activities Selective examinations to cure and prevent disease process Provision of facilities to limit disability and prevent death

mass screening provision of facilities immunizations enviornmental sanitation

The nurse teaches a student nurse about obtaining a female patient's reproductive health history. Which statement, if made by the student nurse, indicates effective learning? "It should be obtained during the pelvic examination." "It should include the pattern of menstruation and sexual satisfaction." "It should focus on physical complaints such as discharge, pain, or rash." "It should be obtained every 3 to 5 years in a patient without complaints."

menstruation and sexual satisfaction

a average sized cuff may crease a false high pressure in what patient

obesity

What are the purposes of obtaining a patient's health history? Documenting the findings of the physical assessment Establishing rapport between the nurse and the patient Assessing and diagnosing the patient's health needs and problems Providing a picture of the patient as a whole Understanding the patient's medical knowledge

patient rapport diagnose health problems and needs patient as a whole

theory that develops interpersonal relationships among nurse and family

peaplau

Which interventions made by the nurse ensure proper assessment in the elderly patient? Select all that apply. Involve the patient in all decision making about the interview. Use medical language with the patient throughout the assessment. Do the assessment after providing privacy in the examination room. Communicate with the patient in an easy-to-hear, high-pitched voice. Include touch whenever necessary while doing a patient assessment.

privacy involvement touch when necessary

state boards of nursing establish what types of laws

regulatory

Relaxation strategies accomlish

relationships communication satisfaction and retention

A nurse is assessing the interactive process of a family. How does the nurse analyze the family's interactive processes? Select all that apply. Assess family transitions. Assess family relationships. Assess the social support of the family. Evaluate the strategies used by the family to cope with stress. Assess family roles.

relationships social support roles

A 56-year-old immigrant client has severe productive cough. The client is diagnosed with tuberculosis (TB) and is placed in an isolation room. What are the possible reasons for this action? To perform a chest X-ray To prevent the spread of infection To provide intravenous fluids To prevent client's exposure to other infections To restrict the client's movement NOT SURE

restrict their movement prevent spread of infection

While completing the assessment of a patient, the nurse reviews the clinical reports and health history, and conducts a physical examination. What other interventions would the nurse perform? Conduct a risk assessment. Set timelines for the outcome. Identify the expected outcome. Conduct a functional assessment. Provide health-promotion teaching.

risk assesment functional assessment

The following nursing diagnoses all apply to one client. As the nurse adds these diagnoses to the care plan, which diagnosis will not include defining characteristics? Risk for aspiration Acute confusion Readiness for enhanced coping Sedentary lifestyle

risk for aspirations

Teaching an older adult how to use e-mail to communicate with a grandchild who lives in another state is an example of _____, which aids cognitive performance by using new approaches. Cognitive development Activity theory Selective optimization with compensation Formal operations

selective optimization with compensation

Which senses does the nurse use while inspecting a patient during a routine physical examination? Select all that apply. Sight Smell Taste Touch Hearing

sight smell

the nurse is obtaining a history from a 7-year-old child with a hand injury. What measures should the nurse take while collecting the history? The nurse should use long questions. The nurse should use scientific terms. The nurse should use simple language. The nurse should use closed-ended questions.

simple language

An elderly debilitated client is admitted to the hospital with hematemesis. The nurse, who is performing oral hygiene, finds that the client is suddenly unable to breathe. The nurse also finds some blood in the client's mouth. What should the nurse do? Select all that apply. Suction the oral airway of the client. Elevate the foot end of the client's bed. Perform tracheal bronchial suctioning. Notify the health care provider immediately. Perform chest compressions on the client.

suction the oral and tracheal bronchial secretions heals care provider should be notified

The nurse is caring for a patient with atherosclerosis. Which intervention should the nurse follow to obtain this patient's ankle-brachial index? Place the patient in the sitting position. Instruct the patient to be in a standing position. Maintain the room temperature at 22 o C (72 o F). Provide fluids to the patient before the examination.

temperature to 72

A nurse is learning about the global nursing shortage that has led to fewer nurses in the workplace. Which essential skills should the nurse learn to ensure professional and efficient client management? Client education Tactless nurturing Time management Compassionate care Therapeutic communication NOT SURE

time management compassionate therapeutic communication education

A nurse assesses an elderly client admitted to the hospital after a fall. What assessment findings could place the client at risk of developing pressure ulcers? Select all that apply. The client has urinary incontinence. The client suffers from hypertension. The client is immobilized due to a leg fracture. The client has impaired sensory perception. The client is confused but can express pain and discomfort.

urine incontinence immobiilty impaired sensory

Which measures does the nurse take when providing a bed bath to an unconscious patient? . Select all that apply. Wet the patient's mouth frequently using a moistened towel Use the same disposable swab for the cheeks and the tongue Use a bite block while providing any oral care for the patient Use bulb syringe suction when providing the patient oral hygiene Place the patient in a supine position with the head elevated NOT SURE

use a bite block bulbe syringe for oral care

a nurse is providing compassionate and empathic care to a patient. Which nursing theory is the nurse using to provide care? Leninger's Cultural Care Theory Swanson's Middle Range Theory of Caring Travelbee's Human-to-Human Relationship Model Watson's Nursing—Human Science and Human Care

Travelbees

Which areas does the nurse assess by using a penlight during an adolescent's physical examination? Select all that apply. Buccal mucosa Palpebral slant Nares and septum Corneal light reflex Tympanic membranes

buccal mucosa nares and nasal septum corneal light reflex

What is the most commonly reported bacterial sexually transmitted infection (STI) in the United States? Syphilis Gonorrhea Genital herpes Chlamydia NOT SURE

chlamydia

The nurse is helping a male patient with shaving. Which actions should the nurse perform when shaving? Give the patient the choice between shaving cream and soap. Use long strokes around the chin and lips. Do not rinse the razor between strokes. Apply warm water to the patient's face with a washcloth for 2 to 3 minutes. Use separate electric razors for each patient because of infection control considerations.

choice between cream and soap used on one patient only short strokes with skin taught warm water

Which actions should the nurse include when educating patients? . Clarify the patient's health-related doubts Teach the patient how to cope with a disease Provide treatment instructions to the patient Explain cellular pathophysiology to the patient Provide numerous medical terms to the patient NOT SURE

clarify health related doubts cope instructions

A client lost a job recently due to poor performance at work and has no alternative source of financial support. The client reports difficulty in sleeping and loss of appetite. On medical examination, there is no organic cause found for the client's symptoms. Which defense mechanism is the client using? Conversion Dissociation Identification Displacement

conversion- anxiety repressed into non-organic symptoms conversion converts

A client diagnosed with pancreatitis complains of pain in the abdomen. Following an initial interview and the assessment, the nurse prepares a nursing care plan. Which guidelines should the nurse follow to reduce errors in the diagnostic statement? Identify medical diagnoses. Identify clinical signs and symptoms. Identify treatable etiology or risk factors. Identify the problems caused by the treatment. Identify the client's response.

etiology/risk factors problems caused by treatment clients response

standard precaution to asepsis

hand hygiene

preeclampsia

high blood pressure swelling of hands and feet protein in urine headaches or vision changes

Which is an actual nursing diagnosis? Risk for acute confusion Impaired social interaction Readiness for enhanced nutrition Readiness for enhanced family coping

impaired social interaction- human response to life process

The nurse formulates several nursing diagnoses after the initial data collection and assessing the client. Which components of a nursing diagnosis are diagnostic labels? Select all that apply. Impaired physical mobility Acute incisional pain Delayed motor response Musculoskeletal injury Impaired sensory perception

impaired/delayed terms impaired moter response deflated motor response impaired physical mobility

What are the essential requirements for performing proper inspection of a patient during physical examination? Select all that apply. Stethoscope Good lighting Ophthalmoscope Sphygmomanometer Adequate exposure of body parts

lighting opthalmoscope adequate exposure

What measures does the nurse use to obtain objective data? Select all that apply. Speak to the patient's family. Conduct a physical examination. Review the laboratory reports. Ask for previous medical records. Conduct an interview with the patient.

physical examination previous records lab reports

What measures should the nurse take to gain the cooperation of a 2-year-old child during a physical examination procedure? Undress the child one part at a time Compliment the child about clothing and toys Talk to the child first, and then talk to the parent Allow the child to keep a personal item such as a teddy bear Praise when the child cooperates during the various assessment steps

praise personal items compliments

A patient is admitted to the hospital with a cervical spinal cord injury and difficulty breathing. Which condition should the nurse monitor for in this patient? Paraplegia Hemiplegia Hemiparesis Quadriplegia NOT SURE

quadriplegia

t he nurse is teaching the clients in a nursing home about good oral hygiene practices. What are the advantages of good oral hygiene practices? Good oral hygiene stimulates the appetite. Good oral hygiene reduces the risk of stroke. Good oral hygiene reduces the risk of nursing home-acquired pneumonia. Good oral hygiene helps with blood sugar control in diabetes. Good oral hygiene includes the consumption of an alkaline diet.

stimulate the apatite infection - blood sugar in diabetes reduces the risk of stroke redues pneumonia in nursing homes

Oral care for cancer therapy

use soft bristle brush with backing soda or floruride toothpaste

A visiting nurse arrives at the home of an older adult who is a diabetic. Which instructions should the nurse give to the client regarding oral hygiene measures? . Select all that apply. "Use a soft-bristled toothbrush." "Replace dentures frequently." "Brush your teeth at least once a day." "Brush your teeth for minimum 90 seconds." "Rinse your mouth minimum four times a day with saline water."

-use a soft toothbrush -9- seconds -rinse 4 times a day

stage 2 hypertension

170/110

How many rights of delegation are required to support safe delegation of patient care? four five six three

5

A nurse has taken a class on legal implications of nursing. To assess the understanding of the students, the nurse asks the student to state an example of statutory law. Which example stated by the students indicates effective learning? Americans with Disabilities Act Laws about the client's right to refuse treatment Laws about acquiring informed consent from the client Laws about the need to report unethical nursing conduct to the State board of nursing

ADA

The nurse uses abbreviations and acronyms while documenting patient information. Which abbreviations can the nurse use while documenting according to the Joint Commission list? IU qd bid CBC 4.0 mg

CBC- complete blood count bid

osteoporosis is a decrease in Vitamin

D

the nurse is caring for an elderly patient who is anxious and lonely. During the interaction, the patient tells the nurse, "My family doesn't care for me, and nobody wants to visit me." Which response would indicate that the nurse is reassuring the patient? "What would you like to eat for lunch?" "Which family member loves you most?" "I will be here to care for you throughout the day." "Tell me something about your family members."

I'll be here

The nurse is providing oral hygiene for an unconscious patient. Which actions should the nurse perform? Select all that apply. Use fingers to hold the patients' mouth open. Use disposable oral swabs dipped in cleaning solution to clean oral tissues. Carefully consider the assistance of unlicensed assistive personnel. Use a bite block or oral airway to hold the mouth open. Use disposable oral swabs dipped in water to clean oral tissues.

NAP disposibal oral swabs dipped in water use bit block or oral airway

A nurse is training a health care provider on precautionary measures to avoid equipment-related accidents. What should be included in the training? Select all that apply. Place a tag on faulty instruments. Promptly report the malfunctions. Follow proper hand hygiene. Follow transmission-based isolation. Assess potential electrical hazards.

Tag on faulty instruments promptly repot mafunctions asses electrical hazards