RN216 EVOLVE 1 CH. 1,2,3,13

Which assessment finding indicates to the nurse that the older client's therapy for dehydration is successful? A. Pulse pressure has decreased. B. Client reports feeling hungry. C. Hematocrit is 58% (0.58 volume fraction). D. Hourly urine output is greater than 15 mL.

D. Hourly urine output is greater than 15 mL.

The nurse is discussing how context influences clinical judgment. What nursing considerations reflect context? (Select all that apply.) A. Environment of care B. Taking a client's temperature C. Availability of electronic health records D. Time pressures within the unit E. Individual nursing knowledge

A. Environment of care D. Time pressures within the unit E. Individual nursing knowledge

Which assessment findings will the nurse consider as possible causes for a client to have a serum potassium level of 6.3 mE/L (mmol/L)? (Select all that apply.) A. Management of hypertension with an angiotensin converting enzyme inhibitor B. Presence of chronic kidney disease C. Vegan diet D. Excessive use of salt substitute E. Daily therapy with a potassium-sparing diuretics F. Past history of hepatitis A

A. Management of hypertension with an angiotensin converting enzyme inhibitor B. Presence of chronic kidney disease D. Excessive use of salt substitute E. Daily therapy with a potassium-sparing diuretics

The nurse prepares to teach a client at risk for increased clotting about interventions to prevent clots. What health teaching would the nurse include? (Select all that apply.) A. "Avoid prolonged periods of sitting." B. "Walk around frequently as much as you can." C. "Avoid crossing your legs when sitting." D. "Drink plenty of fluids, including water." E. "Seek smoking cessation programs if needed." F. "Report any unusual bleeding or bruising."

A. "Avoid prolonged periods of sitting." B. "Walk around frequently as much as you can." C. "Avoid crossing your legs when sitting." D. "Drink plenty of fluids, including water." E. "Seek smoking cessation programs if needed."

A new nurse reports to the nurse preceptor that a client requested pain medication, and when the nurse brought it, the client was sound asleep. The nurse states the client cannot possibly sleep with the severe pain the client described. Which response by the experienced nurse is best? A. "Being able to sleep doesn't mean pain doesn't exist." B. "Have you ever experienced any type of pain?" C. "The client should be assessed for drug addiction." D. "You're right; I would put the medication back."

A. "Being able to sleep doesn't mean pain doesn't exist." A client's description is the most accurate assessment of pain. The nurse would believe the client and provide pain relief. Physiologic changes due to pain vary from client to client, and assessments of them would not supersede the client's descriptions, especially if the pain is chronic in nature. Asking if the new nurse has had pain is judgmental and flippant and does not provide useful information. This amount of information does not warrant an assessment for drug addiction. Putting the medication back and ignoring the client's report of pain serves no useful purpose and is unethical.

Which nursing action reflects systems thinking? A. Giving report to the next shift including client status B. Developing a quality improvement initiative for respiratory assessment C. Documenting the client's lung sounds each shift D. Reviewing best practice for respiratory assessment

B. Developing a quality improvement initiative for respiratory assessment

The nurse is interviewing a transgender client about sexual orientation, gender identity, and health care. Which questions are appropriate as part of the interview? (Select all that apply.) A. "Have you disclosed your gender identity and sexual orientation to your primary health care provider?" B. "Do you have problems being accepted because you are different?" C. "If you have more than one sexual partner, how are you protecting both of you from infections?" D. "Do you have sex with men, women, both, or neither?" E. "Are you in a relationship with someone who lives with you?"

A. "Have you disclosed your gender identity and sexual orientation to your primary health care provider?" C. "If you have more than one sexual partner, how are you protecting both of you from infections?" D. "Do you have sex with men, women, both, or neither?" E. "Are you in a relationship with someone who lives with you?"

The nurse prepares a presentation on promoting a healthy gut at a health fair. Which information should the nurse include to prevent constipation? (Select all that apply.) A. "Increase the amount of fresh fruits and vegetables in diet." B. "Do not ignore the urge to defecate." C. "Use over-the-counter laxatives frequently." D. "Decrease the amount of fiber in diet." E. "Maintain fluid intake of at least 2000 mL/day." F. "Establish a regular exercise routine."

A. "Increase the amount of fresh fruits and vegetables in diet." B. "Do not ignore the urge to defecate." E. "Maintain fluid intake of at least 2000 mL/day." F. "Establish a regular exercise routine."

The nurse is evaluating factors that influence care for a client with diabetes. Which client statement does the nurse identify that reflects a social determinant of health? A. "The grocery store in my neighborhood went out of business." B. "The landlord of my apartment is putting in an access ramp for wheelchairs." C. "I work with a lot of toxic chemicals in my job." D. "Because I live on the bus line, I can ride over to park if I want to get fresh air."

A. "The grocery store in my neighborhood went out of business."

Which nursing action demonstrates use of the principle of justice? A. A 67-year-old client with dementia is shown the same respect as his 47-year-old roommate with prostate cancer. B. An 82-year-old client is provided access to the hospital Patient Advocate for processing of a complaint. C. A 32-year-old client is prevented from falling during the initial postoperative period following her hysterectomy. D. The parents of a 13 year old are included in discussions about the course of their teen's treatment and care.

A. A 67-year-old client with dementia is shown the same respect as his 47-year-old roommate with prostate cancer.

Which client will the nurse consider to be at greatest risk for dehydration?? A. A 75-year-old woman with chronic back pain B. A 25-year-old woman taking oral contraceptives C. A 75-year-old man who has a vitamin deficiency D. A 25-year-old man who has frequent esophageal reflux

A. A 75-year-old woman with chronic back pain

The nurse receives the shift report. Which client would the nurse anticipate a need for arterial blood gas assessment? A. Admitted for excessive salicylate ingestion B. Admitted with chronic pancreatitis C. Recent diagnosis of mild chronic obstructive lung disease D. History of controlled type 2 diabetes

A. Admitted for excessive salicylate ingestion

A nurse uses the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbal client with advanced dementia but no other medical history except well-controlled hypertension and high cholesterol. The client scores a zero. Which action by the nurse is best? A. Assess physiologic indicators and vital signs. B. Do not give pain medication as no pain is indicated. C. Document the findings and continue to monitor. D. Try a small dose of analgesic medication for pain.

A. Assess physiologic indicators and vital signs. Assessing pain in a nonverbal client is difficult despite the use of a scale specifically designed for this population. The hierarchy for assessing pain consists of (1) obtaining a verbal report, which is not possible in this client, (2) consider conditions that might reasonably be painful, (3) observe behaviors, (4) evaluate physiologic indicators, and (5) attempt an analgesic trial. The client is not known to have any conditions that reasonably would cause pain. The nurse would next look at physiologic indicators of pain and vital signs for clues to the presence of pain. Even a low score on this index does not mean that the client does not have pain; he or she may be holding very still to prevent more pain. Documenting pain is important but not the most important action in this case until the nurse has conducted a full assessment. The nurse can try a small dose of analgesia, but without having indices to monitor, it will be difficult to assess for effectiveness.

Which assessment is most important for the nurse to perform on a client whose serum potassium level is 2.0 mEq/L (mmol/L)? A. Checking pulse oximetry B. Measuring blood pressure C. Listening to bowel sounds in all four quadrants D. Observing the ECG for flat T-waves

A. Checking pulse oximetry

Which factor does the nurse identify that influences client outcomes? (Select all that apply.) A. Collaboration between members of the interprofessional health care team B. Health policy legislation at the state and national level C. The culture to which the client identifies D. What the individual client believes about health? E. Technology that is available in the local community health center F. The application of systems thinking to care of clients

A. Collaboration between members of the interprofessional health care team B. Health policy legislation at the state and national level C. The culture to which the client identifies D. What the individual client believes about health? E. Technology that is available in the local community health center F. The application of systems thinking to care of clients

What is the nurse's best first action when a client's hand goes into flexion contractures during blood pressure measurement with an external cuff? A. Deflating the blood pressure cuff and giving the client oxygen B. Documenting the finding as the only action C. Initiating the Rapid Response Team D. Placing the client in the high-Fowler position and increasing the IV flow rate

A. Deflating the blood pressure cuff and giving the client oxygen

Which nursing action reflects the process of prioritize hypotheses, per the NCSBN Clinical Judgement Measurement Model (CJMM)? A. Determining that a new blood pressure reading of 190/100 requires intervention now B. Obtaining vital signs every 4 hours and noting a client's blood pressure as 130/90 C. Administering amlodipine 5 mg orally once daily D. Contacting the registered dietician nutritionist (RDN) to evaluate a client's salt intake

A. Determining that a new blood pressure reading of 190/100 requires intervention now

The nurse is providing health teaching at a health fair about preventing influenza. What adult groups are at risk for contracting this disease due to altered immunity? (Select all that apply.) A. Nonimmunized adults B. Adults who do not practice a healthy lifestyle C. Adults with substance use disorder D. Women who are pregnant E. Older adults F. Adults with chronic illness

A. Nonimmunized adults B. Adults who do not practice a healthy lifestyle C. Adults with substance use disorder E. Older adults F. Adults with chronic illness

The nurse provides client-centered care for an older client who was admitted from an assisted living facility. What attributes would the nurse demonstrate when providing care for this client? (Select all that apply.) A. Physical comfort B. Emotional support C. Client respect D. Communication and education E. Care coordination F. Transition and continuity of care

A. Physical comfort B. Emotional support C. Client respect D. Communication and education E. Care coordination F. Transition and continuity of care

In collaboration with the registered dietitian nutritionist (RDN), which foods will the nurse teach as client who is taking a potassium-sparing diuretic to avoid or use cautiously? (Select all that apply.) A. Red meat B. Cereal C. Citrus fruit D. Salt substitutes E. Eggs F. Bread

A. Red meat C. Citrus fruit D. Salt substitutes

The nurse is caring for a client who was bitten by a spider and has cellulitis. What signs and symptoms would the nurse expect? A. Redness B. Discomfort C. Necrosis D. Warmth E. Swelling

A. Redness B. Discomfort D. Warmth E. Swelling

The nurse is planning care for a client who has decreased mobility. With which interprofessional health care team members would the nurse most likely collaborate? A. Registered dietitian nutritionist (RDN) B. Registered occupational therapist (OTR) C. Primary health care provider (PHCP) D. Respiratory therapist (RT) E. Registered physical therapist (RPT)

A. Registered dietitian nutritionist (RDN) B. Registered occupational therapist (OTR) C. Primary health care provider (PHCP) D. Respiratory therapist (RT) E. Registered physical therapist (RPT)

Which sign or symptom indicates to the nurse that treatment for a client's hypokalemia is effective? A. Reports having a bowel movement daily. B. ECG shows an inverted T wave. C. Fasting blood glucose level is 106 mg/dL. D. Two lb weight gain during the past week.

A. Reports having a bowel movement daily.

Which client electrocardiography (ECG) change from baseline will alert the nurse to possible development of hypercalcemia? A. Shortened QT-interval B. Absent P wave C. Prominent U wave D. Inverted T waves

A. Shortened QT-interval

The nurse is teaching a health and wellness class at a local senior citizen center. When discussing methods to promote cognition, which options would be included? (Select all that apply.) A. Take music lessons. B. Watch television. C. Read the newspaper. D. Complete crossword puzzles. E. Play card games. F. Learn a new language.

A. Take music lessons. D. Complete crossword puzzles. F. Learn a new language.

The nurse is caring for a client who has delirium. Which statement is correct regarding this health problem? A. The focus of managing delirium is to treat the cause. B. Delirium takes months to years to develop. C. The cause of delirium is not known. D. Validation therapy is the best approach for delirium.

A. The focus of managing delirium is to treat the cause.

What effect does the nurse expect that an infusion of 200 mL of albumin will have immediately on a client's plasma osmotic and hydrostatic pressures? A. Decreased osmotic pressure; decreased hydrostatic pressure B. Decreased osmotic pressure; increased hydrostatic pressure C. Increased osmotic pressure; increased hydrostatic pressure D. Increased osmotic pressure; decreased hydrostatic pressure

C. Increased osmotic pressure; increased hydrostatic pressure

A client is put on twice-daily acetaminophen for osteoarthritis. Which finding in the client's health history would lead the nurse to consult with the primary health care provider over the choice of medication? A. 25-pack-year smoking history B. Drinking 3 to 5 beers a day C. Previous peptic ulcer D. Taking warfarin

B. Drinking 3 to 5 beers a day The major serious side effect of acetaminophen is hepatotoxicity and liver damage. Drinking 3 to 5 beers each day may indicate underlying liver disease, which would be investigated prior to prescribing chronic acetaminophen. The nurse would relay this information to the primary health care provider. Smoking is not related to acetaminophen side effects. Acetaminophen does not cause bleeding, so a previous peptic ulcer or taking warfarin would not be a problem.

The nurse in the outpatient surgery clinic is discussing an upcoming surgical procedure with a client. Which information provided by the nurse is most appropriate for the client's long-term outcome? A. "At least you know that the pain after surgery will diminish quickly." B. "Discuss acceptable pain control after your operation with the surgeon." C. "Opioids often cause nausea but you won't have to take them for long." D. "The nursing staff will give you pain medication when you ask them for it."

B. "Discuss acceptable pain control after your operation with the surgeon." The best outcome after a surgical procedure is timely and satisfactory pain control, which diminishes the likelihood of chronic pain afterward. The nurse suggests that the client advocate for himself or herself and discuss acceptable pain control with the surgeon. Stating that pain after surgery is usually short lived does not provide the client with options to have personalized pain control. To prevent or reduce nausea and other side effects from opioids, a multimodal pain approach is desired. For acute pain after surgery, giving pain medications around the clock instead of waiting until the client requests it is a better approach.

About how many mL will the nurse record as having been replaced for a client with dehydration initially weighed 142 lb (64.5 kg) and now weighs 156 lb (70.9 kg) after 2 days of rehydration therapy? A. 3000kg B. 6300kg C. 9300kg D. 7000kg

B. 6300kg

Which client will the nurse recognize as having the greatest risk for development of hypocalcemia? A. A 26 year old with hyperparathyroidism B. A 70 year old who has alcoholism and malnutrition C. A 40 year old taking tetracycline for an infection D. A 35 year old athlete taking NSAIDs for joint pain

B. A 70 year old who has alcoholism and malnutrition

Which client situation reflects the health care system of managed care? A. A client obtains vaccinations at a local community health center that is close to home. B. A client receives an annual physical where the cost has been predetermined as $80. C. A client sees a designed family physician who coordinates all aspects of the client's care. D. A client with abdominal pain is admitted to a hospital for 24 hours of observation.

B. A client receives an annual physical where the cost has been predetermined as $80.

A client has received an opioid analgesic for pain. The nurse assesses that the client has a Pasero Scale score of 3 and a respiratory rate of 7 shallow breaths/min. The client's oxygen saturation is 87%. Which action would the nurse perform first? A. Apply oxygen at 4 L/min. B. Attempt to arouse the client. C. Give naloxone (Narcan). D. Notify the Rapid Response Team.

B. Attempt to arouse the client. The Pasero Opioid-Induced Sedation Scale is used to assess for unwanted opioid-associated sedation. A Pasero Scale score of 3 is unacceptable but is managed by trying to arouse the client in order to take deep breaths and staying with the client until he or she is more alert. Administering oxygen will not help if the client's respiratory rate is 7 breaths/min. Giving naloxone and calling for a Rapid Response Team would be appropriate for a higher Pasero Scale score.

A nurse on the medical-surgical unit has received a hand-off report. Which client would the nurse see first? A. Client being discharged later on a complicated analgesia regimen. B. Client with new-onset abdominal pain, rated as an 8 on a 0-10 scale. C. Postoperative client who received oral opioid analgesia 45 minutes ago. D.. Client who has returned from physical therapy and is resting in the recliner.

B. Client with new-onset abdominal pain, rated as an 8 on a 0-10 scale. Acute pain often serves as a physiologic warning signal that something is wrong. The client with new-onset abdominal pain needs to be seen first. The postoperative client needs at least 30 minutes for the oral medication to become effective and would be seen shortly to assess for effectiveness. The client going home requires teaching, which would be done after the first two clients have been seen and cared for, as this teaching will take some time. The client resting comfortably can be checked on quickly before spending time teaching the client who is going home.

An older adult has diabetic neuropathy and often reports unbearable foot pain. About which medication would the nurse plan to educate the client? A. Desipramine B. Duloxetine C. Morphine sulfate D. Nortriptyline

B. Duloxetine Antidepressants and anticonvulsants often are used for neuropathic pain relief. Morphine would not be used for this client. However, SNRIs are better tolerated than tricyclics, which eliminate desipramine and nortriptyline. Duloxetine would be the best choice for this older client.

A hospitalized client has a history of depression for which sertraline is prescribed. The client also has a morphine allergy and a history of alcoholism. After surgery, several opioid analgesics are prescribed. Which one would the nurse choose? A. Hydrocodone and acetaminophen B. Hydromorphone C. Meperidine D. Tramadol

B. Hydromorphone Hydromorphone is a good alternative to morphine for moderate to severe pain. The nurse would not choose the combination with acetaminophen because it contains acetaminophen and the client has a history of alcoholism. Tramadol would not be used due to the potential for interactions with the client's sertraline. Meperidine is rarely used and is often restricted.

The nurse is caring for a client diagnosed with bowel and bladder incontinence. Which is a priority collaborative problem for this client? A. Indequate nutrition B. Impaired skin integrity C. Altered level of consciousness D. Decreased fluid volume

B. Impaired skin integrity

The nurse is caring for a client at end of life. What is the nurse's priority for the client's care? A. Promote coping. B. Increase comfort. C. Ensure adequate nutrition. D. Maintain breathing

B. Increase comfort.

A nurse is caring for a client who received intraspinal analgesia. Which action by the nurse is most important to ensure client safety? A. Assess and record vital signs every 4 hours. B. Instruct the client to report any unrelieved pain. C. Monitor for numbness and tingling in the legs. D. Perform frequent neurologic assessments.

B. Instruct the client to report any unrelieved pain. Complications from intraspinal anesthesia are rare, but can be life threatening. The nurse would perform frequent neurologic assessments and notify the primary health care provider for abnormal findings. Vital signs are taken every 1 to 2 hours for at least 12 hours. Unreported pain is managed, but this is not a safety concern. Numbness and tingling outside of the surgical site is not normal, but can usually be abated by decreasing the opioid dose. The nurse can also keep the client on bedrest, decreasing safety concerns, while reporting to the primary health care provider.

The nurse requests a conference with members of the interprofessional health care team regarding care for a complex client. Which Interprofessional Education Collaborative Competency does this request represent? A. Role-Responsibilities B. Interprofessional Communication C. Values/Ethics for Interprofessional Practice D. Teams and Teamwork

B. Interprofessional Communication

Nurses at a conference learn the process by which pain is perceived by the client. Which processes are included in the discussion? (Select all that apply.) A. Induction B. Modulation C. Sensory perception D. Transduction E. Transmission F. Transition

B. Modulation C. Sensory perception D. Transduction E. Transmission The four processes involved in making pain a conscious experience are modulation, sensory perception, transduction, and transmission.

Which assessment finding on a client with hypervolemia indicates to the nurse that the client's condition may be worsening? A. Nose and ears have a slightly yellow-tinged appearance. B. Neck veins are now distended in the sitting position. C. Breath sounds can be heard in the right lower lung lobe. D. Weight is unchanged from that obtained yesterday.

B. Neck veins are now distended in the sitting position.

A nurse gives report about a client whose pain in uncontrolled and suggests that the client receive continuous analgesic administration rather than PRN analgesics. Which step of the SBAR hand-off report is the nurse using? A. S B. R C. B D. A

B. R

The nurse is teaching a health and wellness class. What would the nurse include in the discussion of common risk factor for impaired cellular regulation? (Select all that apply.) A. Drinking alcohol B. Smoking C. Over the age of 70 D. Poor nutrition E. Physical inactivity

B. Smoking C. Over the age of 70 D. Poor nutrition E. Physical inactivity

The nurse is teaching a class on systems thinking in nursing. What teaching will the nurse include? (Select all that apply.) A. Systems thinking is not affected by health policy at the national level. B. The complexity of client care can affect systems thinking C. Systems thinking shifts the focus from safety to quality in care. D. It is important for the nurse to place all focus on individualized client care. E. Systems thinking allows the nurse to assess the root of problems. F. Interprofessional, collaborative care is fostered when using systems thinking.

B. The complexity of client care can affect systems thinking E. Systems thinking allows the nurse to assess the root of problems. F. Interprofessional, collaborative care is fostered when using systems thinking.

Into which environment of care would the nurse anticipate sending a client who is experiencing complications from COVID-19? A. Medical home B. Community health care C. Inpatient care D. Rehabilitation care

C. Inpatient care

After receiving the change-of-shift report, which client does the nurse assess first? A. A 67 year old with nausea and vomiting who reports abdominal cramps. B. A 77 year old with normal saline infusing at 150 mL/hr with an average hourly urine output of 75 mL. C. A 57 year old receiving IV diuretics whose blood pressure is 88/52 mm Hg. D. A 45 year old with a nasogastric (NG) tube who has dry oral mucosa and reports feeling very thirsty.

C. A 57 year old receiving IV diuretics whose blood pressure is 88/52 mm Hg.

A nurse participates as part of a quality improvement (QI) team to develop a plan to "reduce deep vein thrombosis on a surgical unit." What part of the PICO(T) question does this statement represent? A. P B. C C. O D. I

C. O

Which principal nursing actions best support a focus on client safety? (Select all that apply.) A. Respect for others B. Client restraints C. Preoperative checklists D. Handwashing E. Five rights of drug administration

C. Preoperative checklists D. Handwashing E. Five rights of drug administration

Which assessments are most important for the nurse to perform to prevent harm on a client with a sodium level of 118 mEq/L (mmol/L)? (Select all that apply.) A. Testing skin turgor B. Asking about any abdominal pain C. Assessing cognition D. Checking deep tendon reflexes E. Monitoring urine output F. Checking for the presence of fever

C. Assessing cognition E. Monitoring urine output

Which assessment is most important for the nurse to perform on a client who is receiving IV magnesium sulfate? A. Monitoring 24-hour urine output B. Monitoring the serum calcium levels C. Assessing the blood pressure hourly D. Asking the client whether a headache is present

C. Assessing the blood pressure hourly

A nurse is caring for four clients receiving pain medication. After the hand-off report, which client would the nurse see first? A. Client who is crying and agitated B. Client with a heart rate of 104 beats/min C. Client with a Pasero Scale score of 4 D. Client with a verbal pain report of 9

C. Client with a Pasero Scale score of 4 The Pasero Opioid-Induced Sedation Scale has scores ranging from S to 1 to 4. A score of 4 indicates unacceptable somnolence and is an emergency. The nurse would see this client first. The nurse can delegate visiting with the crying client to a nursing assistant; the client may be upset and might benefit from talking or a comforting presence. The client whose pain score is 9 needs to be seen next, or the nurse can delegate this assessment to another nurse while working with the priority client. A heart rate of 104 beats/min is slightly above normal, and that client can be seen after the other two clients are cared for.

A new nurse asks the precepting nurse "What is the best way to assess a client's pain?" Which response by the nurse is best? A. Numeric pain scale B. Behavioral assessment C. Client's self-report D. Objective observation

C. Client's self-report Many ways to measure pain are in use, including numeric pain scales, behavioral assessments, and other objective observations. However, the most accurate way to assess pain is to get a self-report from the client.

The nurse is teaching a class on clinical judgment. What teaching will the nurse include? A. Clinical judgment is a fixed process. B. Clinical judgment is not required to make an informed decision. C. Clinical judgment is an outcome of critical thinking. CD. linical judgment happens outside the context of the scenario.

C. Clinical judgment is an outcome of critical thinking.

Which assessment on an older client with some degree of dehydration will the nurse perform to determine whether the client is safe for independent ambulation? A. Ensuring that the most recent serum potassium level is above 3.5 mEq/L (mmol/L) B. Assessing for furrows on the tongue to determine dryness of oral mucous membranes C. Comparing blood pressure measurements in the lying, sitting, and standing positions D. Ensuring that the pulse rate obtained radially is within 2 beats/min of that obtained apically

C. Comparing blood pressure measurements in the lying, sitting, and standing positions

The nurse notes that a client has a pale cool left leg without palpable pulses. What would be the nurse's best action at this time? A. Continue to monitor the client's left leg. B. Document the assessment findings. C. Contact the Rapid Response Team (RRT). D. Elevate the client's left leg.

C. Contact the Rapid Response Team (RRT).

What response does the nurse expect to see in the blood volume and blood osmolarity of a client whose secretion of aldosterone is abnormally low? A. Decreased blood volume; increased blood osmolarity B. Increased blood volume; decreased blood osmolarity C. Decreased blood volume; decreased blood osmolarity D. Increased blood volume; increased blood osmolarity

C. Decreased blood volume; decreased blood osmolarity

Which nursing element reflects systems thinking at the global level of practice? A. Facility health policy B. Quality improvement initiative C. Determinants of health D. Interprofessional practice

C. Determinants of health

Bedside (point-of-care) computers are an example of informatics used in health care primarily for which purpose? A. Enhancing collaboration and coordination of care B. Offering clients access to email and the Internet C. Documenting interprofessional care D. Retrieving data for evidence-based practice

C. Documenting interprofessional care

A nurse is assessing pain on a confused older client who has difficulty with verbal expression. Which pain assessment tool would the nurse choose for this assessment? A. Numeric rating scale B. Verbal Descriptor Scale C. FACES Pain Scale-Revised D. Wong-Baker FACES Pain Scale

C. FACES Pain Scale-Revised All are valid pain rating scales; however, some research has shown that the FACES Pain Scale-Revised is preferred by both cognitively intact and cognitively impaired adults. A confused client with difficulty speaking would not be a good candidate for the numeric rating scale or the verbal descriptor scale. The cartoon images on the Wong-Baker FACES Pain Scale may not be appropriate for an adult client.

Which nursing action reflects the QSEN competency of Patient-Centered Care? (Select all that apply.) A. Designing nursing care with a focus on keeping the client safe B. Participating on a committee that is evaluating the newest bar-code scanner C. Including the client in discussions about dietary choices D. Respecting the client's preference about treatment options E. Referring to a nursing journal to consider trends in care F. Using data collected over the past quarter to determine if and how nursing care should change

C. Including the client in discussions about dietary choices D. Respecting the client's preference about treatment options

Which action will the nurse perform first to prevent harm for a client suspected to have fluid overload? A. Checking for presence of dependent edema B. Assessing blood pressure C. Measuring intake and output D. Elevating the head of the bed

D. Elevating the head of the bed

A registered nurse is caring for a client who is receiving pain medication via patient-controlled analgesia (PCA). Which action by the nurse indicates the need for further education on pain control with PCA? A. Assesses the client's pain level per agency policy. B. Monitors the client's respiratory rate and sedation. C. Presses the button when the client cannot reach it. D. Reinforces client teaching about using the PCA pump.

C. Presses the button when the client cannot reach it. The client is the only person who should press the PCA button. If the client cannot reach it, the nurse would either reposition the client or the button, and would not press the button for the client. Pressing the button for the client ("PCA by proxy") indicates the need to review the information about this treatment modality. The other actions are appropriate.

Which condition or symptom indicates to the nurse that the client's treatment for hyperkalemia is effective? A. Chvostek sign is negative. B. Respiratory rate is 22 breaths/min. C. Pulse rate is 76 beats/min and regular. D. Hematocrit is 42%.

C. Pulse rate is 76 beats/min and regular.

As a result of work completed by a quality improvement (QI) team, a new nursing protocol for preventing catheter-associated urinary tract infections (CAUTIs) is piloted. Which step of the PDSA QI model is associated with this action? A. P B. D C. S D. A

C. S

The nurse supports the client and family in deciding on a "Do Not Resuscitate" order. Which ethical principle that guides nursing clinical decision making is demonstrated in this situation? A. Legality B. Beneficence C. Self-determination D. Justice

C. Self-determination

Which body areas are best for the nurse to use when assessing skin indications of hydration status for an older client? (Select all that apply.) A. Tops of the forearms B. Skin of the shins C. Skin of the forehead D. Skin over the abdomen E. Skin over the sternum F. Back of the hand

C. Skin of the forehead E. Skin over the sternum

Which serum electrolyte value indicates to the nurse that the client has hypernatremia? A. Sodium 132 mEq/L (mmol/L) NORMAL RANGE 135-145 mEq/L B. Potassium 3.5 mEq/L (mmol/L) NORMAL RANGE 3.5- 5.0 mEq/L C. Sodium 148 mEq/L (mmol/L) D. Potassium 5.3 mEq/L (mmol/L)

C. Sodium 148 mEq/L (mmol/L)

What does the nurse recognize is the fastest growing technology being used for informatics? A. Drug information libraries B. Medication bar code administration C. Telehealth and telenursing D. Electronic health record

C. Telehealth and telenursing

Which of these hospital staff members will the nurse manager request to coordinate the discharge of a client who will need community-based rehabilitation services after a traumatic injury? A. The primary health care provider assigned as the client's medical resident B. The physical therapist who developed the client's exercise program C. The nurse responsible for the client's case management D. The unit-based RN who has cared for the client during the hospital stay

C. The nurse responsible for the client's case management

Which actions are considered best practices for the nurse to use during the administration of parenteral potassium to a client with a serum potassium level of 1.9 mEq/L (mmol/L) (Select all that apply.) A. Keeping the client NPO during drug treatment B. Pushing the drug as a bolus slowly over 5 minutes C. Using an IV controller to deliver the drug D. Checking IV access for blood return after the infusion E. Initiating the IV in a hand vein for rapid access F. Ensuring that the concentration is no greater than 1 mEq/10mL (mmol/10 mL) of solution

C. Using an IV controller to deliver the drug F. Ensuring that the concentration is no greater than 1 mEq/10mL (mmol/10 mL) of solution

Which laboratory value indicates to the nurse that a client's hyponatremia may be related to a fluid volume excess? A. Serum chloride level is 100 mEq/L (mmol/L) NORMAL RANGE 96-106 mEq/L B. Blood urea nitrogen (BUN) is elevated NORMAL RANGE 10-20 mg/dL C. Arterial blood pH is 7.37 NORMAL RANGE 7.34-7.45 D. Hematocrit is 29% (0.29 volume fraction)

D. Hematocrit is 29% (0.29 volume fraction) NORMAL RANGE 37%-47% female/ 42%-52% male

A nurse asks why several clients are getting more than one type of pain medication instead of very high doses of one medication. Which response by the charge nurse is best? A. "A multimodal approach is the preferred method of control." B. "Clients are consumers and they demand lots of pain medicine." C. "We are all much more liberal with pain medications now." D. "Pain is so complex it takes different approaches to control it."

D. "Pain is so complex it takes different approaches to control it." Pain is a complex phenomenon and often responds best to a regimen that uses different types of analgesia. This is called a multimodal approach. Using this terminology, however, may not be clear to the newer nurse if the terminology is not understood. Primary health care providers and nurses may be more liberal with different types of pain medications, but that is not the best reason for this approach, especially in light of the opioid epidemic. Saying that clients are consumers who demand medications sounds as if the charge nurse is discounting their pain experiences.

The nurse is assessing a client's pain and has elicited information on the location, quality, intensity, effect on functioning, aggravating and relieving factors, and onset and duration. Which question by the nurse would be best to ask the client for completing a comprehensive pain assessment? A. "Are you worried about addiction to pain pills?" B. "Do you attach any spiritual meaning to pain?" C. "How high would you say your pain tolerance is?" D. "What pain rating would be acceptable to you?"

D. "What pain rating would be acceptable to you?" A comprehensive pain assessment includes the items listed in the question plus the client's opinion on a comfort-function outcome, such as what pain rating would be acceptable to him or her. Asking about addiction is not warranted in an initial pain assessment. Asking about spiritual meanings for pain may give the nurse important information, but getting the basics first is more important. Asking about pain tolerance may give the client the idea that pain tolerance is being judged.

When developing a standardized plan of care for clients with a diagnosis of pneumonia, how does the nurse find the best information about providing optimal nursing care? A. Survey experienced RNs about which nursing actions are effective when caring for clients with pneumonia. B. Research the most recent articles in nursing magazines that discuss care for clients with pneumonia. C. Review the chart to determine what primary health care provider's prescriptions are frequently written for clients with pneumonia. D. Access a website that reports on randomized controlled studies on nursing care for clients with pneumonia.

D. Access a website that reports on randomized controlled studies on nursing care for clients with pneumonia.

A nurse on the postoperative inpatient unit receives hand-off report on four clients using patient-controlled analgesia (PCA) pumps. Which client would the nurse see first? A. Client who appears to be sleeping soundly. B. Client with no bolus request in 6 hours. C. Client who is pressing the button every 10 minutes. D. Client with a respiratory rate of 8 breaths/min.

D. Client with a respiratory rate of 8 breaths/min. Continuous delivery of opioid analgesia can lead to respiratory depression and extreme sedation. A respiratory rate of 8 breaths/min is below normal, so the nurse would first check this client. The client "sleeping soundly" could be comfortable (no indicators of respiratory distress) and would be checked next. Pressing the button every 10 minutes indicates that the client has a high level of pain, but the device has a lockout determining how often a bolus can be delivered. Therefore, the client cannot overdose. The nurse would next assess that client's pain. The client who has not needed a bolus of pain medicine in several hours has well-controlled pain.

The nurse is designing a program to make vaccines available to as many people as possible. Into which environment is the vaccine most likely to be introduced first? A. Medical home B. Inpatient care C. Long-term care D. Community Health Center

D. Community Health Center

What is the best action for a nurse to take on finding a client's serum chloride level is 101 mEq/L? A. Urge the client to drink more water. B. Notify the primary health care provider. C. Assess the client's deep tendon reflexes. D. Document the finding as the only action

D. Document the finding as the only action

Which action will the nurse perform first for the client who has a serum potassium level of 6.9 mEq/L (mmol/L)? A. Teaching the client which foods to avoid B. Administering sodium polystyrene sulfonate orally C. Collaborating with the registered dietitian nutritionist to provide a potssium-restricted diet D. Initiating continuous cardiac monitoring

D. Initiating continuous cardiac monitoring

The nurse is providing care for a client who recently had a brain attack. Which member of the interprofessional health care team does the nurse identify that can help the client improve skills to perform ADLs? A. Assistive personnel B. Physical therapist C. Licensed social worker D. Occupational therapist

D. Occupational therapist

The nurse is comparing the clinical judgment measurement model (CJMM) and the nursing process. Which step of the CJMM is specific to analysis? A. Generate solutions B. Take actions C. Recognize cues D. Prioritize hypothesis

D. Prioritize hypothesis

The nurse is caring for a client who is immobile. The client is most at risk to develop which complication? A. Hypertension B. Muscle hypertrophy C. Diarrhea D. Renal calculi

D. Renal calculi

A client who had surgery has extreme postoperative pain that is worsened when trying to participate in physical therapy. Which intervention for pain management does the nurse include in the client's care plan? A. As-needed pain medication after therapy B. Pain medications prior to therapy only C. Patient-controlled analgesia with a basal rate D. Round-the-clock analgesia with PRN analgesics

D. Round-the-clock analgesia with PRN analgesics Severe pain related to surgery or tissue trauma is best managed with round-the-clock dosing. Breakthrough pain associated with specific procedures is managed with additional medication. An as-needed regimen will not control postoperative pain. A patient-controlled analgesia pump might be a good idea but needs bolus (intermittent) settings to accomplish adequate pain control, with or without a basal rate. Pain control needs to be continuous, not just administered prior to therapy.

A nurse is assessing pain in an older adult. Which action by the nurse is best? A. Ask only "yes-or-no" questions so the client doesn't get too tired. B. Give the client a picture of the pain scale and come back later. C. Question the client about new pain only, not normal pain from aging. D. Sit down, ask one question at a time, and allow the client to answer.

D. Sit down, ask one question at a time, and allow the client to answer. Some older clients do not report pain because they think it is a normal part of aging or because they do not want to be a bother. Sitting down conveys time, interest, and availability. Ask only one question at a time and allow the client enough time to answer it. Yes-or-no questions are an example of poor communication technique. Giving the client a pain scale, and then leaving, might give the impression that the nurse does not have time for the client. Also, the client may not know how to use it. There is no normal pain from aging.

A nurse is preparing to give a client ketorolac intravenously for pain. Which assessment findings would lead the nurse to consult with the primary health care provider? A. Bilateral lung crackles B. Hypoactive bowel sounds C. Self-reported pain of 3/10 D. Urine output of 20 mL/2 hr

D. Urine output of 20 mL/2 hr Drugs in this category can affect renal function. Clients need to be adequately hydrated and demonstrate good renal function prior to administering ketorolac. A urine output of 20 mL/2 hr is well below normal, and the nurse would consult with the primary health care provider (PHCP) about the choice of drug. Crackles and hypoactive bowel sounds are not related. A pain report of 3 does not warrant a call to the PHCP.

Which nursing action reflects Assessing, per the AAPIE model of Assessing, Analyzing, Planning, Implementing, and Evaluating? (Select all that apply.) A. Administers IV furosemide 40 mg as prescribed. B. Sets a goal for client to resume normal activities within 4 weeks following surgery. C. Compares temperature at 0600 with temperature taken at 1200. D. Contacts health care provider after obtaining blood pressure of 200/100. E. Collects information about how client sustained an injury. F. Notes pressure injury of 2 inches by 1 inch on sacrum.

E. Collects information about how client sustained an injury. F. Notes pressure injury of 2 inches by 1 inch on sacrum.