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Which of the following clients should the nurse monitor vital signs every four hours?

A client hospitalized for high blood pressure.

Which of the following clients likely faces a risk for the nursing diagnosis of Disturbed Sleep Pattern: Difficulty Remaining Asleep?

A client who receives IV antibiotics every three hours

Which individual is at greater risk for respiratory illnesses from environmental causes?

A factory worker in a large city

Some religious beliefs may conflict with prevalent health care practices. For example, what type of treatment is prohibited by the doctrine of Jehovah's Witnesses?

Administering blood transfusions

What does pulse oximetry measure?

Arterial oxygen saturation

A nurse is caring fora client who is unconscious. Which of the following is a recommended guideline for communication with this client?

Be careful what is said in front of the client as he or she might hear you.

A client is brought to the emergency department in an unconscious condition. The client's wife hands over the previous medical files and points out that the client had suddenly fallen unconscious after trying to get out of bed. Which of the following is a primary source of information?

Client's wife

A nurse caring for critically ill clients uses interventions to help clients maintain a sense of self.Which of the following are recommended interventions?

Converse with the client about his or her life experience

Although all of the following are factors that affect grief, which one is most likely to influence a person's expression of grief?

Cultural influences

A nurse is ordered to perform digital removal of stool on a client with stool impaction. Which of the following is an appropriate step in this procedure?

Gently work the finger around and into the hardened mass to break it up and then remove pieces of it

The client is under immediate stress. The nurse assesses which sign as an effect of the sympathetic system?

Heart rate of 102 beats/minute

What safety device for children is mandated by law in all 50 states?

Infant car seats and carriers

What spiritual need is believed to underlie all religious traditions and is common to all people?

Love and relatedness

A client in the hospital emergency department tells the nurse, "I feel lousy and I've had bad diarrhea for several days. It must have been something I ate. I have nausea and I don't feel like eating or drinking." The nurse obtains the vital signs and the practitioner orders lab studies. What should the nurse conclude most likely is the client's human response based on the client's comments and after reviewing the client's chart

Metabolic acidosis

A student is preparing for her first client care assignment. She wakes up at 4 AM with a pounding pulse and diarrhea. What type of adaptive response to stress is she experiencing?

Mind-body interaction

A nurse is teaching anew diabetic client to administer insulin. How will the nurse evaluate if the teaching interventions were appropriate?

Observe the client demonstrate an insulin injection and correctly identify the injection site rotation.

A client says, "What is that awful smell?" What sense is being used?

Olfactory

A nurse is caring fora client who is ambulating for the first time after surgery. Upon standing, the client complains of dizziness and faintness. The client's blood pressure is 90/50. What is the name for this condition?

Orthostatic hypotension

When measuring the size, depth, and wound tunneling of a client's stage IV pressure ulcer, what action should?

Perform hand hygiene.

An individual steps into a tub of very hot water and immediately jumps out again. What mechanism caused this response?

Reflex pain response

A nurse is educating a lawn-care worker on the risk of hearing loss. What might be recommended?

Wear earplugs while using lawn equipment

When obtaining a client's history, the nurse should

ask questions about the client's reason for seeking care.

The charge nurse is making assignments for a team of two RNs and one licensed practical/vocational nurse (LPN/VN). The nurse should delegate the care of which client to the LPN/VN?

client who is who had a abdominal hysterectomy 2 days ago; vital signs are stable

A client has received numerous different antibiotics and now is experiencing diarrhea. What type of precautions should the nurse institute

contact precautions

The nurse is caring for a toddler in contact isolation for respiratory syncytial virus (RSV). In what order from first to last should the nurse remove personal protective equipment (PPE)?

gloves, gown, goggles, mask

A nurse is caring fora client with a history of falls. The nurse's first priority when caring for a client at risk for falls is

keeping the bed in the lowest possible position

While caring for a client who's immobile, a nurse documents the following information in the client's chart: "Turned client from side to back every 2 hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." Which nursing diagnosis accurately reflects this information?&

risk for impaired skin integrity related to immobility

The nurse is placing a client with severe neutropenia in reverse isolation. What should the nurse tell the client why this is necessary? Reverse isolation helps prevent the spread of organisms

to the client from sources outside the client's environment.

The nurse should utilize SBAR communication (Situation, Background, Assessment, Recommendation) during which clinical situation?

when communicating a change in a client's condition to their physician

To which unlicensed assistive personnel should the nurse assign a male orthodox Muslim client who needs complete morning care?

Joe, who has one client requiring complete morning care

A nurse makes a medication error and fills out an incident report. What will the nurse do with the incident report once it is filled out?

Maintain it according to agency policy.

A nurse does not assist with ambulation for a postoperative client on the first day after surgery. The client falls and fractures a hip. What charge might be brought against the nurse?

Negligence

A man with urinary incontinence tells the nurse he wears adult diapers for protection. What risks should the nurse discuss with this client?

Skin breakdown and UTI

The right hand of a client with multiple sclerosis trembles severely whenever she attempts a voluntary action. She spills her coffee twice at lunch and cannot get her dress fastened securely. Which is the best legal documentation in nurses' notes of the chart for this client assessment?

Slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup.

A middle-aged, overweight adult man has had hypertension for 15 years. What pathologic event is he most at risk for?

Stroke

A home care client reports weakness and leg cramps. Per order, the nurse draws blood and requests a potassium level. What is the rationale for this request?

The nurse recognizes these symptoms of hypokalemia.

Of the following individuals, who can best determine the experience of pain?

The person who has the pain

A client gets out of bed following hip surgery, falls, and re-injures her hip. The nurse caring for her knows that it is her duty to make sure an incident report is filed. Which of the following statements accurately describes the correct procedure for filing an incident report?

The report should contain all the variables related to the incident

Which of the following hospital units is more likely to cause severe sensory alterations?

Intensive care

A client has been prescribed a clear liquid diet. What food or fluids will be served?

Jell-O, carbonated beverages, apple juice

A nurse administers morphine sulfate as ordered for pain. The client experiences nausea and vomiting and a decrease in respiratory rate. When documenting this event in the health record, which data would be considered subjective data?

Client seems very nauseated

A client with diabetes has impaired sensation in her lower extremities. What education would be necessary to reduce her risk of injury?

Always test the temperature of bath water before stepping in.

While reviewing the chart for an assigned client before beginning care, a student notes that the client does not belong to a specific religion. Based on this information, what should the student interpret about the client

A person may be deeply spiritual but not profess a religion.

Which client will have an increased metabolic rate and require nutritional interventions?

A person with a serious infection and fever

A woman has had a breast removed to treat cancer. What type of loss will she most likely experience?

Actual loss

A client is experiencing hypoxia. Which of the following nursing diagnoses would be appropriate?

Anxiety

The nurse is preparing a teaching plan for an adult recently diagnosed with type 2 diabetes mellitus. What is the first step in this process?

Assess the client's learning needs.

A male client who has had outpatient surgery is unable to void while lying supine. What can the nurse do to facilitate his voiding?

Assist him to a standing position.

A nurse is discharging a client from the hospital. When should discharge planning be initiated?

At the time of admission to an acute health care setting

nurse fails to administer a medication that prevents seizures, and the client has a seizure. The nurse is in violation of the Nurse Practice Act. What type of law is the nurse in violation of

Civil

How may a nurse demonstrate cultural competence when responding to clients in pain?

Avoid stereotyping responses to pain by clients.

A client complains of severe abdominal pain. To elicit as much information as possible about the pain, the nurse should ask

Can you describe the pain?

A client has soft wrist restraints to prevent the client from pulling out the nasogastric tube. Which nursing intervention should be implemented while the restraints are on the client?

Check on the client every 30 minutes while the restraints are on.

A nurse is caring fora client who is a celebrity in the area. A person claiming he is a family member inquires about the medical details of the client. The nurse reveals the information but later comes to find out that the person was not a family member. The nurse has violated which of the following?

Confidentiality

A nurse is caring for a client who is a chronic alcoholic. The nurse educates the client about the harmful effects of alcohol and educates the family on how to cope with the client and his alcohol addiction. Which of the following skills is the nurse using?

Counseling

Which of the following is an example of a closed-ended question or statement?

Did you take those drugs?

A nurse enters a client's room and finds that the client has fallen on her way to the bathroom. Which of the following is a prudent nursing intervention for this client?

Document the incident, assessment, and interventions in the client's medical record.

Legally speaking, how would the nurse ensure that care was not negligent?

Documenting the nursing actions in the client's record

A nurse is caring fora middle-aged client who looks worried and flares his nostrils when breathing. The client complains of difficulty in breathing, even when he walks to the bathroom. Which of the following breathing disorders is most appropriate to describe the client's condition?

Dyspnea

A nurse is conducting a health history for a client with a chronic respiratory problem. What question might the nurse ask to assess for orthopnea?

How many pillows do you sleep on at night to breathe better?

Which of the following questions or statements would be most useful for the nurse to make when eliciting information about a client's sexual history?

How would you describe the problem?

A client reports that her naps after lunch often stretch to three hours in length and that she has great difficulty rousing herself after a nap. This condition is best termed as which of the following?

Hypersomnia

While caring for a client near end of life, a student talks to her. Another student asks why she is talking to someone who is dying. Which response would be accurate?

I believe the client can hear me as long as she is alive.

A nurse is educating adolescents on how to prevent infections. What statement by one of the adolescents indicates that more education is needed?

I don't wear a condom when I have sex, but I know my partners

A client tells the nurse, "I am an atheist. I do not believe in God." What would be an appropriate response by the nurse?

I respect what you choose to believe in.

A registered nurse assigns the task of tracheostomy suctioning of a client to the LPN. The LPN informs the nurse that she has never done the procedure practically on a client. What should be the most appropriate response from the registered nurse?

I will help you in performing the procedure on the client.

Which expected outcome demonstrates the effectiveness of a plan of care to promote rest and sleep?

Identifies factors that interfere with normal sleep pattern

When is the best time to evaluate one's own teaching effectiveness?

Immediately after an education session

Which of the following is an example of the body's defense against infection?

Immune response

What intervention should be included on a plan of care to prevent pressure ulcer development in health care settings?

Implement a turning schedule every two hours.

A nurse is documenting a variance that has occurred during the shift, and this report will be used for quality improvement to identify high-risk patterns and potentially initiate in-service programs. This is an example of which type of report?

Incident report.

A patient has developed edema in her lower legs and feet, prompting her physician to prescribe furosemide (Lasix), a diuretic medication. After the client has begun this new medication, what should the nurse anticipate?

Increased output of dilute urin

In what age group would a nurse expect to assess the most rapid respiratory rate?

Infants

A nurse is caring fora young client who is dying of renal failure. What should the nurse do when caring for the dying client's family members?

Inform the family members that it is time to bid farewell to the client

A client is diagnosed with a terminal illness. Who is usually responsible for deciding what, when, and how the client should be told?

Physician

A client is suing a nurse for malpractice. What is the term for the person bringing suit?

Plaintiff

A hospitalized client has been NPO with only intravenous fluid intake for a prolonged period. What assessments might indicate protein-calorie malnutrition

Poor wound healing, apathy, edema

A nurse is preparing to educate a client about care at home. On entering the room, she finds the client pacing around the room, hyperventilating, and complaining of nausea. Based on these manifestations of severe anxiety, what would the nurse do?

Postpone implementation of the education plan.

Of all possible nursing interventions to break the chain of infection, which is the most effective?

Practicing hand hygiene

The nurse caring for a client with emphysema has determined that a priority nursing diagnosis for this client is "Imbalanced Nutrition: Less Than Body Requirements related to difficulty breathing while eating." Based upon this diagnosis, which of the following is an appropriate nursing intervention to include in the client's care plan?

Provide six small meals daily.

A nurse realizes that data has been entered on the wrong client's written health record. Which step should the nurse take to correct this documentation error?

Put a line through the entry, leaving the content visible, and initial.

Which activity would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)for a client diagnosed with a myocardial infarction who is stable?

Record the intake and output.

A client with a diagnosis of colorectal cancer has been presented with her treatment options, but wishes to defer any decisions to her uncle, who acts in the role of a family patriarch within the client's culture. By which of the following is the client's right to self-determination best protected?

Respecting the client's desire to have the uncle make choices on her behalf

The nurse interprets the values as being

Respiratory alkalosis

A client with hearing loss gets very frustrated trying to carry on conversations with friends. Which typeof stressor is the client experiencing?

Sensory deficits

A young client died following a cardiac arrest. The nurse caring for the client and the family notes that some members of the family refuse to accept that the client has died. What stage of grief is the family experiencing?

Shock and disbelief

The nursing student asks the nurse for an example of a "never event." Which example provided by the nurse best answers the nursing student's question?

The client scheduled for a cholecystectomy has a total abdominal hysterectomy

A nurse forgets to raise the bed railings of a client who is confused after taking pain medications. The client attempts to get out of bed, and suffers a minor fall. The nurse asks a colleague who witnessed the fall not to mention it to anyone because the client only had minor bruises. What would be the appropriate action of the colleague?

The colleague should inform the nurse that a full report of the incident needs to be made

An older adult woman of Chinese ancestry refuses to eat at the nursing home, stating, "I'm just not hungry." What factors should the staff assess for this problem

The food served may not be culturally appropriate.

During a clinical placement on a subacute, geriatric medicine unit, a student nurse fed a stroke client some beef broth, despite the fact that the client's diet was restricted to thickened fluids. As a result, the client aspirated and developed pneumonia. Which of the following statements underlies the student's potential liability in this situation?

The same standards of care that apply to a registered nurse apply to the student.

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse refuses.Who among the following is entitled to access client records?

Those directly involved in the client's care.

What is the primary purpose of the outcome identification and planning step of the nursing process?

To design a plan of care for and with the client

What intervention is recommended to reduce sensory stimulation for infants in the neonatal ICU?

Use limited light

A nurse is carrying out an order to remove an indwelling catheter. What is the first step of this skill?

Wash hands and put on gloves.

The nurse assists the client to the operating room table and supervises the operating room technician preparing the sterile field. Which action, completed by the surgical technician,

Wetness in the sterile cloth on top of the nonsterile table has been noted.

A nurse is feeding a client. Which of the following statements would help a person maintain dignity while being fed?

What part of your dinner would you like to eat first?

A nurse is caring fora client with acute back pain. When should the nurse assess the client's pain?

Whenever the vital signs are measured and documented

A nurse is performing a sterile dressing change. If new sterile items or supplies are needed, how can they be added to the sterile field?

With sterile forceps or hands wearing sterile gloves

During a taped shift report, the evening nurse reports that a client has been "annoying all evening, and has been demanding and on the call bell constantly." The nurse manager of the unit overhears this part of the report. Which of the following statements represents the best response by the nurse manager to the evening nurse?

Your report was subjective and did not address the cause of the behavior

The following statement appears on a client's care plan: "Client will ambulate in the hall without assistance within 4 days." This statement is an example of

a client outcome.