Principles Final

A nurse consults with a nurse practitioner trained to perform acupressure to teach the method to a client being discharged. What process is involved in this pain relief method?

Cutaneous stimulation

Which is a characteristic of a person-centered relationship?

An unequal sharing of information

What is the average adult fluid intake and loss in each 24 hours?

1,500 to 3,500 mL

Which nursing group provides a definition and scope of practice for nursing?

American Nurse Association (ANA)

Which activity related to respiratory health is an example of tertiary health promotion and illness prevention?

Administering a nebulized bronchodilator to a client who is short of breath

What type of law regulates the practice of nursing?

Civil law

A nurse provides client care within a philosophy of ethical decision-making and professional expectations. What is the nurse using as a framework for practice?

Code of Ethics

pH-7.39 PaCO2-46 HCO3-28

Compensated Respiratory Acidosis

Which is true of concepts?

Concepts describe objects, properties, and events and the relationship among them

A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status?

Daily weights

The nurse reviews the laboratory test results of a client and notes that the client's potassium level is elevated. What would the nurse expect to find when assessing the client's gastrointestinal system?

Diarrhea

A nurse states to the client that the nurse will keep the client free of pain. However, the client's family wishes to try a treatment to prolong the client's life that may necessitate withholding pain medication. This factor will cause an ethical dilemma for the nurse in relation to which ethical principle?

Fidelity

Which part of the client's record is commonly used to document specific client variables such as vital signs?

Flow sheets

A nurse has just received a client's laboratory results and is reviewing them. Which finding should the nurse recognize as an indication of malnutrition or malabsorption?

Hematocrit (Hct) 56% (0.56)

During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible?

Hypovolemia

Which statement accurately represents a recommended guideline when providing postoperative care for the following clients?

If vital signs are progressively increasing or decreasing from the baseline, notify the health care provider of possible internal bleeding

Which statement most accurately defines illness?

Illness is the response of a person to a disease

Arterial blood gases reveal that a client's pH is 7.20. What physiologic process will contribute to a restoration of correct acid-base balance?

Increased respiratory rate

A client is admitted to the hospital with a serum potassium level of 2.8 mEq/L. The nurse anticipates that assessment findings will include which of the following?

Irregular pulse rate and shallow respirations

Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume?

Isotonic

Which interpersonal skill is essential to the practice of nursing?

Keeping personal information among shared clients confidential

A client with an inflamed appendix is feeling pain in the stomach area. What is the term for this body response to stress?

Local adaptation syndrome

A nurse is reviewing nursing theory for usefulness in a home healthcare setting. Which is the appropriate application of Dorothea Orem's Self Care model in a home healthcare setting?

Match the client's self-care needs with appropriate supportive interventions

A nurse uses the SBAR method in a hand-off report to communicate to the health care team about the client. Which element should the nurse cover in the "B" section of the SBAR report?

Mental status

pH-7.55 PaCO2-40 HCO3-32

Metabolic Alkalosis

The following are prescriptions on a client's record. Which prescriptions would the nurse question because they are written incorrectly?

Metoprolol 25mg po daily, hold if BP<100mmHg Heparin 5000U subcutaneously every day Vancomycin 750mg IV qod

The nurse should place highest priority on which nursing intervention for a client in renal failure who has a potassium of 6.8?

Obtain an ECG

pH-7.34 PaCO2-50 HCO3-28

Partially Compensated Respiratory Acidosis

pH-7.31 PaO2-92 PaCO2-50 HCO3-28

Partially Compensated Respiratory Alkalosis

A client age 56 years is experiencing withdrawal from alcohol and is placing themselves at risk for falls by repeatedly attempting to scale the bed rails. Benzodiazepines have failed to alleviate the clients agitation and the nurse is considering obtaining an order for physical restraints to ensure client safety. The nurse should recognize that this measure may constitute:

Paternalism

A nurse is thinking back on a clinical situation that occurred several days ago and how they responded to that situation. Upon entering the client's room, the nurse observed the client experiencing shortness of breath. The nurse identified this as a significant change in the client's status and assessed the client further. The nurse responded by elevating the head of the bed for the client and administering supplemental oxygen at a flow rate. The nurse also notified the HCP about the client's status and received additional orders. The nurse's actions constitute which process?

Reflection

What action by a nurse will help a client meet self-esteem needs?

Respect the client's values and belief systems

A client with a diagnosis of colorectal cancer has been presented with the treatment options, but wishes to defer any decisions to an uncle, who acts in the role of a family patriarch in a client's culture. The client's right to self-determination is best protected by:

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

pH-7.52 PaCO2-32 HCO3-26

Respiratory Alkalosis

A specially trained nurse has inserted a PICC line. What would be done next?

Send the client to the radiology department

The nurse has engaged the services of an interpreter when interviewing a client who speaks a language that the nurse does not understand. The interpreter is functioning in which role during the communication process?

Sender

Accreditation by which organization is legally required for a school of nursing to exist?

State Board of Nursing

Which guideline should a nurse use when choosing a position (location) in relation to a client during a verbal interaction?

Take note of the client's cues when choosing a position and act on these cues

The nurse talks with a client who states, "My primary care provider wants me to try a TENS unit for my pain. How can electricity decrease my pain?" Which response is most appropriate?

The mild electrical impulses block the pain signal before it can reach the brain

A nurse is providing care in a hospital setting. Who has full legal responsibility and accountability for the nurse's actions?

The nurse

What is the primary focus of FOCUS charting?

To concentrate on the client and client concerns in documentation

During the hospital admission interview, a client begins to cry when asked about number of pregnancies. Which communication technique would the nurse employ during this interaction?

Use of silence

What is the best example of community based nursing?

Visiting a mother and newborn baby to ensure satisfactory bonding.

A nurse is conducting a health history interview for an older adult. Which question or statement should the nurse prioritize for nutritional assessment?

Which prescribed and over-the-counter medicines do you take?

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

mind-body interaction