transitions exam 1

The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. When should the nurse inflate the balloon?

advance the catheter to the bifurcation and inflate the balloon

The nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L (5.5 mmol/L). The nurse understands that a potassium value at this level would be noted with which condition?

traumatic burn

The nurse has completed diet teaching for a client who has been prescribed a low-sodium diet to treat hypertension. The nurse determines that there is a need for further teaching when the client makes which statement?

"Fresh foods such as fruits and vegetables are high in sodium."

An older woman is brought to the emergency department. When caring for the client, the nurse notes old and new ecchymotic areas on both of the client's arms and buttocks. The nurse asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her daughter frequently hits her if she gets in the way. Which is the appropriate nursing response?

"I have a legal obligation to report this type of abuse."

An antihypertensive medication has been prescribed for a client with hypertension. The client tells the nurse that she would like to take an herbal substance to help lower her blood pressure. Which statement by the nurse is most important to provide to the client?

"You will need to talk to your primary health care provider (HCP) before using an herbal substance."

The nurse is caring for a client following a craniotomy in which a large tumor was removed from the left side. In which position can the nurse safely place the client? Refer to Figures 1 to 4.

#1 with the HOB elevated

The nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are performed and the serum calcium level is 12.0 mg/dL (3.0 mmol/L). Based on this laboratory value, the nurse should take which action?

Inform the registered nurse of the laboratory value.

After a client undergoes a liver biopsy, the nurse places the client in the prescribed right-side lying position. The nurse understands that the purpose of this intervention is to accomplish which?

Limit bleeding from the biopsy site

the client ask the nurse about various herbal therapies available for the treatment of insomnia. the nurse should encourage the client to discuss the use of which product with the primary health care provider?

valerian

A clear liquid diet has been prescribed for a client with gastroenteritis. Which item is appropriate to offer to the client?

Fat-free beef broth

A client is having problems with blood clotting. Which food item should the nurse encourage the client to eat?

Green, leafy vegetables

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse collect data from first?

A client receiving oxygen who is having difficulty breathing

The nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which describes the team-based model of nursing practice?

Nursing staff are led by the nurse when providing care to a group of clients.

The nurse is assigned to care for a client who has a chest tube. The nurse is told to monitor the client for crepitus (subcutaneous emphysema). Which method should be used to monitor the client for crepitus?

Palpating the skin around the chest and neck for a crackling sensation

The nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department. The nurse should assign priority to which client?

A client with chest pain who states that they just ate pizza that was made with a very spicy sauce

The nurse finds the client lying on the floor. The nurse calls the registered nurse, who checks the client and then calls the nursing supervisor and the primary health care provider to inform them of the occurrence. The nurse completes the incident report for which purpose?

A method of promoting quality care and risk management

A nurse is hired to replace a staff member who has resigned. After working on the unit for several weeks, the nurse notices that the unit manager does not intervene when there is conflict between team members, even when it escalates. Which of the following conflict resolution strategies is the unit manager demonstrating?

avoidance

The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse should tell the client that which food item is least likely to contain calcium?

butter

The nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL (3.25 mmol/L). Which prescribed medication should the nurse plan to assist in administering to the client?

calcitonin

The nurse is assigned with caring for a client who has a chest tube. The nurse notes fluctuation of the fluid level in the water seal chamber. Based on this observation which action would be appropriate?

continue to monitor

The nurse has delegated several nursing tasks to staff members. Which is the nurse's primary responsibility after the delegation of tasks?

Perform follow-up with each staff member regarding the performance and outcome of the task.

The nurse has inserted a nasogastric (NG) tube in a client and is checking for the correct placement of a NG tube. Which is the most reliable data to ensure that the end of the tube is in the stomach?

Placement is verified on x-ray.

The nurse reviews the client's serum calcium level and notes that the level is 8.0 mg/dL (2.0 mmol/L). The nurse understands that which condition would cause this serum calcium level?

Prolonged bed rest

A client has died, and the nurse asks a family member about the funeral arrangements. The family member refuses to discuss the issue. Which is the appropriate nursing action?

Remain with the family member without discussing funeral arrangements

The nurse observes that a client received pain medication 1 hour ago from another nurse, but the client still has severe pain. The nurse has previously observed this same occurrence several times. Based on the nurse practice act, the observing nurse should plan to take which action?

Report the information to a nursing supervisor

The nurse arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the pediatric unit. Which is the appropriate nursing action?

Report to the pediatric unit and identify tasks that can be safely performed.

The nurse is providing dietary instructions to a client with gout. The nurse should tell the client to avoid which food item?

Scallops

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse check first?

A client who is dependent on a ventilator

The nurse employed in a long-term care facility is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assistive personnel (UAP)?

A client who requires a 24-hour urine collection

The nurse is planning the client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel (UAP)?

A client who requires frequent ambulation

The nurse is assigned to assist with caring for a client with esophageal varices who had a Sengstaken-Blakemore tube inserted because other treatment measures were unsuccessful. The nurse should check the client's room to ensure that which priority item is at the bedside?

A pair of scissors

The nurse is recording a nursing hands-off (end-of-shift) report for a client. Which information needs to be included?

As-needed medications given that shift

A client experiences cardiac arrest. The nurse leader quickly responds to the emergency and assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership style?

Autocratic

A low-sodium diet has been prescribed for a client with hypertension. Which food selected from the menu by the client indicates an understanding of this diet?

Baked turkey

A client with heart disease is instructed regarding a low-fat diet. The nurse determines that the client understands the diet if the client states to avoid which food item?

Cheese

A nurse lawyer provides an education session to the nursing staff regarding client rights with emphasis on invasion of client rights. The nurse lawyer asks a staff nurse to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right?

Taking photographs of the client without consent

The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L (130 mmol/L). The nurse expects that this sodium level would be noted in a client with which condition?

The client with the syndrome of inappropriate secretion of antidiuretic hormone

The nurse is planning to reinforce nutrition instructions to an African American client. When reviewing the plan, the nurse is aware that which food may be a common dietary practice of clients with African American heritage?

fried foods

The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which sign/symptom would be an indication of this electrolyte imbalance?

generalized muscle weakness

a nurse is participating in a quality improvement study of procedure frequently performed on the unit. which of the following info will provide data regarding the efficacy of the procedure?

incidence of complications related to procedure

The nurse reinforces instructions to a client to increase the amount of riboflavin in the diet. The nurse should tell the client to select which food item that is high in riboflavin?

milk

An unconscious client, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which is the best action?

Transport the client to the operating department immediately without obtaining an informed consent.

The nurse who is caring for a client with kidney failure notes that the client is dyspneic and crackles are heard when listening to breath sounds in the lungs. Which additional sign/symptom should the nurse expect to note in this client?

an increase in bloodpressure

an PN ending her shift reports to the RN that a newly hired AP has not calculated the intake and output for several clients. which of the following actions should the RN take?

ask the AP is she needs assistance

The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding should the nurse expect to note as a result of this long-term use?

increased specific gravity of the urine

a nurse enters the room of a client who is on contact precautions and finfds the client lying on the floor. which of the following actions should the nurse take first?

inspect the client for injuries

a nurse manager is working with a committee of nurses to update policies for new employee orientation. the nurse manager directs the team to collect as much data as possible and recommend several options. which of the following decision-making styles us the nurse manager demonstrating?

integrative

A client with a burn injury is transferred to the nursing unit, and a regular diet has been prescribed. The nurse encourages the client to eat which dietary items to promote wound healing?

Chicken breast, broccoli, strawberries, and milk

The nurse enters a client's room and notes that the client's lawyer is present and that the client is preparing a living will. The living will requires that the client's signature be witnessed, and the client asks the nurse to witness the signature. Which is the appropriate nursing action?

Decline to sign the will.

The licensed practical nurse (LPN) enters a client's room and finds the client lying on the bathroom floor. The LPN calls the registered nurse, who checks the client thoroughly and then assists the client back into bed. The LPN completes an incident report, and the nursing supervisor and primary health care provider (PHCP) are notified of the incident. Which is the next nursing action regarding the incident?

Document a complete entry in the client's record concerning the incident

A hospitalized client is a lacto-vegetarian. Which food item should the nurse remove from the meal tray?

Eggs

The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse should place the client in which position for insertion?

High Fowler's position

The nurse is assigned to assist with caring for a client after cardiac catheterization performed through the left femoral artery. The nurse should plan to maintain bed rest for this client in which position?

Supine with head elevation no greater than 30 degrees

A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should plan to place the client in which position?

Supine, with the residual limb supported with pillows

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse asks the client to assume a left Sims' position. The nurse explains that this positioning is preferred because of which reason?

The enema will flow into the bowel easily.

the nurse is caring for a group of clients who are taking herbal medications at home. which client should be given instructions with regard to avoiding the use of herbal medications?

a 10 year old female client with a urinary tract infection

the nurse is preparing to assist a client of orthodox jewish faith with eating lunch. a kosher meal is delivered to the client. which nursing action is appropriate when assisting the client with the meal?

allowing the client to unwrap utensils and prepare his own meal for eating

The nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L (5.4 mmol/L). What should the nurse look for on the cardiac monitor as a result of this laboratory value?

narrow peaked t waves

An RN on a medical-surgical unit is making assignments at the beginning of the shift. Which of the following tasks should the nurse delegate to the LPN?

obtain vital signs for a client who us 2 hr post-procedure following a cardiac catheterization

The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which additional sign/symptom should the nurse expect to note in this client if hyponatremia is present?

postural bloodpressure changes

The nurse is assisting with collecting data from an African American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which information about the client is of lowest priority during the data collection?

psychosocial

The nurse consults with a dietitian regarding the dietary preferences of an Asian American client. Which food should the nurse suggest to include in the diet plan?

rice

a client is diagnosed with cancer and is told that surgery followed by chemotherapy will be necessary. the client states to the nurse, "I have read a lot about complementary therapies. Do you think I should try any?" The nurse should respond by making which appropriate statement?

tell me what you know about complementary therapies

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for a potassium deficit?

the client receiving nasogastric suctioning

The nurse is reading the primary health care provider's (PHCP's) progress notes in the client's record and sees that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." Which client is at risk for this loss?

the client with a fast resp. rate

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for fluid volume deficit?

the client with a ileostomy

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at the least likely risk for the development of third-spacing?

the client with diabetes mellitus

A Hispanic American mother brings her child to the clinic for an examination. Which is most important when gathering data about the child?

touching the child during the examination