161 Lecture

When documenting information in a client's medical record, what should the nurse do consistently for each entry?

Sign each entry by name and title.

Which of the following is stated in a living will?

Wishes regarding health care if terminally ill

A nurse is caring for an older adult client who has just died in a hospice unit. The child of the client arrives and asks, "Can I please stay and sit at the bedside? I really wanted to be here so they did not die alone." Which statement made by the nurse best demonstrates the use of empathy?

"I will close the door so you can spend some quiet time at the bedside."

The nurse has arranged to start an IV line for a client with pancreatitis. The nurse notes that the client appears anxious about the procedure. What is the most appropriate response by the nurse to decrease the client's anxiety?

"I will start an IV so I can administer fluids directly into your vascular system."

While covering a colleague's lunch break, a nurse on an orthopedic unit has responded to a client's call light. The client has requested assistance in transferring from the bed to the bathroom. The nurse has not previously provided care for this client and is unsure of the client's current activity orders. The client's current level of activity can be most easily verified by consulting what written source?

Active Orders

A client with stage II cancer has opted to use reflexology and herbal therapy for treatment. The nurse understands this treatment falls under which modality?

Alternative therapy

When caring for a client at the health care facility, the nurse observes that the client is having difficulty understanding the health education. Which action is most appropriate?

Assess for cultural differences.

The nurse is caring for a patient who has experienced significant pain following a surgical procedure. Which nursing interventions are appropriate?

Assess for pain control 30 minutes after administering an analgesic Consider cultural implications of the perception of pain Provide pain medication before an activity that will increase pain

The nurse is educating an older adult about products that cause bleeding that should be avoided before surgery. Which products should the nurse include? (Select all that apply.)

Baby Aspirin ibuprofen warfarin ginko

A student wants to join a nursing program that provides flexibility in working at both staff and managerial positions. Which nursing program should the nurse suggest for this student?

Baccalaureate nursing programs

Two nurses are discussing appropriate care of culturally diverse populations and a nurse has made the point that the United States is diverse but anglicized. Why is the United States considered to be anglicized?

Because United States culture evolved primarily from the early English settlers

Calcium

Ca+

A nurse is caring for a patient with excessive abdominal fat. The nurse should inform the client about the risk associated with excessive abdominal fat. What is the risk?

Cardiovascular Disease

A nurse is caring for a client with a terminal illness. Which statement is true of a terminal illness?

Recovery is beyond reasonable expectation.

A client at a health care facility has died after a prolonged illness. A nurse is assigned to perform postmortem care for the client. Which intervention should the nurse perform when providing postmortem care?

Cleanse drainage from the skin.

The unlicensed assistive personnel was reluctant to allow the Muslim client room for a prayer rug in her room. The inability to recognize the values, beliefs, and practices of others because of strong ethnocentric preferences is which of the following?

Cultural blindness

To ensure an accurate analysis, the nurse collects a specimen in an appropriate container, labels the container with the correct information, attaches the proper lab request form, and ensures that the specimen is taken to the lab. What is the last step that the nurse must take to ensure analysis of the specimen?

Deliver the specimen to the lab as soon as possible.

A nurse caring for a client with depression. The nurse finds that the client is withdrawn and does not communicate with others. What is the most appropriate response by the nurse?

Did you like your dinner?

When maintaining medical records for a client, the nurse knows that a medical record also serves as a legal document of evidence. What is one important aspect of legal defensible charting?

Ensure that the client's name appears on all pages.

The nurse notes that a diabetic client has been readmitted to the health care facility with a high blood sugar level as the client had not followed the proper diet. The client is unable to read and speak English properly and can only sign their name. Which category does the client fall into?

Functionally illiterate

A nurse is planning the care of a client who will soon begin radiotherapy for the treatment of breast cancer. The nurse has been identifying interventions that are rooted in the notion of holism, which states that:

Interactions between the mind and the body can profoundly influence health.

The client is disabled veteran with bilateral above the knee amputation (AKA). The client frequently has tender, erythemic areas along the incision lines which requires observation. Which type of facility will provide the appropriate care for this client?

Intermediate Care facility

Potassium

K+

A client has been admitted to the healthcare facility for less than 24 hours for observation. The client has a gold ring, watch, reading glasses, and other personal belongings. What care should the nurse take with regard to these objects?

List each item on a valuables form and describe each item and lock in a safe or locker for the client.

An Arab client has been admitted to the health care facility with varicose veins. What should the nurse avoid while conducting the interview of the client?

Maintaining eye contact

Magnesium

Mg+

A child recovering from a traumatic injury is encouraged to express feelings through pictures. The nurse recognizes this as which type of therapy?

Mind-body therapy

Sodium

Na+

A nurse is caring for a client with multiple sclerosis. The client informs the nurse that a lawyer is coming to prepare a living will and requests the nurse to sign as witness. Which actions should the nurse take?

Note that the nurse caring for the client cannot be a witness.

Phosphate

PO4-

A client at a health care facility has been diagnosed with an upper respiratory disorder. The nurse understands that which of the following structures forms a part of the upper airway?

Pharynx

A client is scheduled for thyroidectomy as part of treatment for thyroid cancer. Which aspect of care will be conducted in the receiving room of the operating department?

Preoperative medications are administered

Managed care organizations are insurers that carefully plan and closely supervise the distribution of healthcare services. What is one of the goals of managed care?

Preventing illness through screening and promotion of health activities

A nurse notes that vomiting occurs with great force in a client with Gastrointestinal Bleeding. What term should the nurse document relating to this condition?

Projectile Vomiting

A nurse is providing care for client who experienced a stroke and has expressive aphasia (the person knows what he or she wants to say, yet has difficulty communicating it to others). Which nursing intervention reflects tertiary level of prevention?

Provide care transition at discharge for speech therapy.

A nurse is caring for a young client who is dying of acute renal failure. What care should the nurse take when helping dying clients to cope?

Provide opportunities for the client to express his feelings freely

The nurse is preparing to teach a client from Generation X about hypertension. Which teaching approach will the nurse plan to implement?

Refer to the American Heart Association website, Demonstrate MyFoodPyramid phone app, to show the best food choices on a lunch tray.

The patient is undergoing a lumbar puncture. What post procedural instruction would the nurse give to the patient? (Select all that apply)

Remain flat on your back for the next several hours. Report any drainage from the puncture site. Increase fluids for the next few hours which will help restore fluid levels.

A nurse is caring for a client with myasthenia gravis. The client is having difficulty forming words and his tone is nasal. Which communication strategy is an effective one for this client?

Repeat what the client has said to verify the meaning of what was said and to avoid misunderstanding.

The nurse is preparing a client to undergo an endoscopy. What is the appropriate nursing responsibility? (Select all that apply.)

Reporting any incorrect test preparations promptly before the procedure. Ensuring that the client has an identification bracelet on. Reviewing the medical record to ensure that the consent has been signed.

A child has been admitted to the medical center with severe depression and stress, and has been avoiding going to school for these reasons. What would be the most beneficial action by the nurse?

Talk with the child and try to discover what has caused stress and depression

All of the following are examples of output except:

Tears

A home care nurse is caring for a paralyzed client who needs regular position changes and back massages. A man identifying himself as a family friend inquires if he can be of any help to the family. What should be the nurse's response be?

The nurse should ask the man to talk to the family directly.

A client experienced a fight or flight response immediately following a car accident. What clinical symptoms would the nurse expect? (Select all that apply.)

decreased digestion Pale appearance increased heart rate heightened awareness

what is the position?

dorsal lithotomy

A nurse has received change-of-shift report and is briefly reviewing the documentation about a client in the client's medical record. A recent entry reads, "Client was upset throughout the morning." To improve this entry regarding detailed charting, it should:

include clearer descriptions of the client's mood and behavior.

what is the position?

prone

what is the position?

sim's

what is the position?

supine

A nurse caring for a client at a health care facility has to maintain a medical record for the client. Which of the following is a use of the medical record?

to document the quality of care the agency provided

A client made a formal request to review their medical records. With review, the client believes there are errors within the medical record. What is the most appropriate nursing response?

"According to HIPAA legislation, you have a right to request changes to inaccurate information."

A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate?

"Any papers with client data should not leave the unit."

The nursing instructor is teaching a nursing student about the definition of diversity. Which teaching will the nursing instructor include?

"Diversity demonstrates differences among groups of people."

A client who is bedridden is scheduled to receive subcutaneous injections of heparin at 8:00 a.m. and 8:00 p.m. each day. The client's medication administration record would present these times as:

0800 and 2000

A process that required an energy molecule such as ATP to move substances across a membrane

Active transport

The nurse enters the room and the client is grimacing and guarding the abdomen. The client reports, "I have pain." What is the nurse's first priority?

Assess the patient's level of pain and assess vital signs.

A client reports to the emergency department with ankle pain due to a minor road accident. By asking the client to describe the accident, which type of nursing skill is the nurse using?

Assessment skills

The patient has been diagnosed with congestive heart failure causing increased edema and has been placed on fluid restriction. What are some nursing implications that might be considered for this patient? Select all that apply.

Assist with frequent oral hygiene Avoid sweet drinks and foods that are dry and salty Work out a plan for distributing fluid throughout the day

A client who came in through the emergency department with a severely fractured leg will be transported to surgery within the hour. When the client asks how long hospitalization will occur after surgery, what is the appropriate nursing response?

Because you are having inpatient surgery, you will be at least 1 day after surgery

what is the position?

Dorsal Recumbent

The nurse plans to collect a sputum specimen from a client for laboratory diagnosis after the client awakens. Which of the following reasons explains the nurse's choice of an early morning collection?

Ensures more mucus is available

A nurse is reinforcing wound edges and applying a blinder to the separated incisions of a client after a surgery. Which postoperative complication has the client developed?

Evisceration

The patient is experiencing third-spacing. A cause might be:

Hypoalbuminemia

Hypovolemia may result in the following: Select all that apply.

Hypotension Decreased Skin Tugor

A client suffered a spinal cord injury during a motor vehicle accident which necessitated the creation of a tracheostomy. What nursing diagnosis should the nurse recognize as a likely consequence of this intervention?

Impaired verbal communication

Allowing unauthorized people to observe a client during treatment is an example of which of the following?

Invasion of privacy

The nurse is preparing a client who is having a routine prostate examination. What is the most appropriate position for the client?

Modified Standing

Which clients would require intake and output monitoring? Select all that apply

Patients receiving IV therapy Patients receiving tube feedings Patient with a urinary catheter Patients who have undergone surgery Patients with wound drainage using a wound draining system

A client is admitted to the health center with chronic diarrhea which might be related to diet therapy. It has been determined that special dietary instruction is needed. When should the nurse initiate instruction about the benefits of this special diet to the client so that the risk of diarrhea is minimized?

When admitting the client

A nurse is applying a pneumatic compression device to a client. What is the purpose of a pneumatic compression device?

promotes circulation of venous blood

A client has been admitted to the hospital in anticipation of surgery that is scheduled for later that afternoon. The nurse has taken the opportunity to perform preoperative teaching and is emphasizing the importance of leg exercises during the postoperative period. What instruction should the nurse provide to this client?

"Bend one of your knees and then raise and hold the leg over your mattress for a few seconds."

The caregiver of a client who is terminally ill is becoming short tempered with the client and states, "I just can't take this anymore." Which nursing response is most appropriate?

"Have you considered respite care so that you can rest for a few days?"

Which client statement would cause the nurse to suspect that the stage of bargaining has been reached in the grief process?

"If I can just live long enough to see my daughter get married."

What is the best response by the nurse when explaining biofeedback to a client?

"It allows a reduction of symptoms through voluntary control measures."

A nurse completing admission paperwork asks the client about having an advanced directive. The client states, "I do not know, what is an advanced directive?" What is the nurse's best response?

"It is a written document that identifies a person's preferences regarding which medical interventions to use in the event of a terminal condition."

A client asks the nurse how cortisol works. What is the appropriate nursing response?

"It raises blood glucose and inhibits insulin along with suppressing the immune response."

A female client reports to her primary care physician with aggravated chest pain. The physician orders a stress test. The client tells the nurse that she does not want to take the test and feels she should instead continue with the medication a little longer. Understanding that the client is anxious, what is the most appropriate response by the nurse?

"Tell me more about how you are feeling."

A nurse visits a female victim of sexual assault for the fourth visit. The client expresses that she is unable to cope with the trauma. Even though the assault occurred quite some time ago, she feels as if it just happened yesterday. What is the most appropriate response by the nurse?

"Tell me more about the aspects that make you feel as if it happened yesterday."

An English-speaking Hispanic male has undergone a resection of the colon. The nurse observes that the client is restless and is unable to sleep. What should be the nurse's initial statement to the client?

"Tell me what you are feeling."

A client is scheduled for thoracentesis. The nurse assesses that the client appears anxious about the procedure and needs honest support and reassurance. What is the most appropriate response by the nurse to this client?

"The needle causes discomfort upon insertion, but I will be by your side throughout and will help you hold your position."

The healthcare provider has prescribed a short-acting beta-2 agonist (SABA) for a client with a history of bronchospasm. What teaching about this drug will the nurse include?

"This drug is to be used as a rescue inhalant."

The daughter of an older client is concerned that her mother is depressed because she is reading the obituaries every day. What is the most appropriate nursing response?

"This is common in older adults and doesn't necessarily indicate depression."

A nurse is collecting a health history on a client. When asked about alcohol, tobacco, and drug use, the client states, "I quit smoking 10 years ago." However, the nurse observes an open package of cigarettes in the client's shirt pocket. What is the most appropriate response by the nurse?

"You said that you do not smoke, but you have an open package of cigarettes in your pocket. Let's discuss.

The nursing student asks the instructor why it is important for them to know about the law and ethics when they will be taking care of client's physical and psychosocial needs and not be practicing law. What is the best response by the instructor?

"You will need to have a basic understanding of laws and ethics because it may affect your practice."

Thirty milliliters equals:

1 ounce

A nurse needs to use a wall suction machine on an adult client with breathing difficulties due to chest congestion, as per the order from the client's physician. What amount of negative pressure should the nurse apply for this client?

100 to 140 mm Hg

The nurse is caring for (4) clients. Which does the nurse identify as highest risk for Cardiometabolic Syndrome?

36 year old with obesity who smokes

A nurse uses suction to remove liquid secretions from a client's chest. How far should the nurse advance the catheter in the client's nose so that the distal tip is placed in the client's pharynx?

5 to 6 inches

The nurse works at an agency that automatically places certain clients on intake and output I/O. For which client will the nurse document all I/O?

55 year old with congestive heart failure and is on a diuretic such as furosemide

The nurse is caring for four clients. Which client does the nurse identify as the highest risk for social readjustment concerns?

77-year old whose spouse just died

The nurse is preparing to teach four clients. Which client will the nurse plan to teach using principles associated with gerogogy?

79-year old who has slight cognitive changes

A registered nurse (RN) is making the assignments for the oncoming staff which client would the RN assign to the LPN?

A client who needs bedside blood glucose testing before meals and at bedtime

A nurse is performing an assessment of a newly admitted hospital client and has documented the client as being a member of the Native American subculture. A subculture is best described as:

A cultural group with values that are incongruent with those of the dominant culture

A client is a member of a group insurance plan in which he pays a preset, fixed fee for healthcare services. What type of insurance plan does the nurse understand the client to have?

A health maintenance organization (HMO)

A client is dying of Alzheimer disease and is being cared for in an inpatient setting for his last days. In anticipation of the client's imminent death, assessments and interventions have been limited to those necessary to maintain comfort. However, the nurse has taken a set of vital signs in response to signs of multiple organ failure. What vital signs are consistent with multiple organ failure? Select all that apply.

A weak, thready pulse

A nurse is teaching a client in a long-term care facility the proper technique for performing postural drainage. Which of the following suggestions should the nurse give to the client?

Administer prescribed inhalant medications before performing postural drainage.

A client with abdominal incisions experiences excruciating pain when he tries to cough. What should the nurse do to reduce the client's discomfort when coughing?

Administer prescribed pain medication 30 minutes before deliberately attempting to cough.

The nurse observes that a client responds better to health education when the nurse motivates him and assures him about the benefits of the teaching. In which of the following learning domains does the client's learning style fall?

Affective domain

A client who tends to volunteer to complete major assignments (but forgets to complete his own work) is stressed because of this. The nurse suggests that the client prioritize his work, complete the difficult part of his work first, and delegate the rest of the work to colleagues. In this case, what technique is the nurse asking the client to follow?

Alternative behaviors

An anion is:

An ion that has a negative charge

A cation is:

An ion that has positive charge

A nurse is caring for a terminally ill client. The client is exhibiting signs of multiple organ failure. Which of the following signs indicates failure of the liver?

Anorexia

The nurse is preparing for a client for laser procedure. Which nursing intervention is appropriate?

Apply goggles to client.

The nurse is caring for a terminally ill client who is from Mexico. Which nursing intervention regarding spiritual care is appropriate?

Ask the client if a spiritual leader is desired.

The nurse is caring for a 70-year-old client with a fractured wrist and is in need of instruction regarding medication therapy. Which of the following is the best method to determine if the client has retained the information taught?

Ask the client to recall the information after approximately 15 minutes.

The nurse is completing discharge instructions for an Asian American client. The nurse can best evaluate the likeliness of the client to adhere to the instructions by use of which method?

Ask the client whether there is anything in the discharge plan that will interfere with compliance.

The nurse manager hears a nurse and a UAP talking about a female client who reports pain of 8-10 on a scale of 1-10 after a Caesarean birth to deliver twins. The nurse states, "I don't believe she has any pain at all. I'm sure is just drug seeking." What is the appropriate nurse manager action?

Ask to speak to the nurse privately for a moment, and educate about bias in pain treatment

A nurse is conducting an interview of a 40-year-old client who is admitted with chest pain. Which action by the nurse indicates active listening?

Asking for clarifications and repetitions

An 81-year-old client is being rehabilitated in an inpatient setting following her recovery from the acute stages of a stroke. The stroke resulted in dysphagia, which creates a risk of what respiratory problem?

Aspiration of food or fluid

A nurse warns a client with a history of seizure activity that he may fall off his bed during a seizure if he does not raise the upper side rails of the bed. Before leaving the client's room, the nurse raises the upper side rails, but after the nurse leaves the room, the client lowers them again. Later, the client has a seizure and falls from the bed. The client attempts to holds the nurse responsible for it. Which legal provision protects the nurse in this case?

Assumption of risk

A client with multiple sclerosis (MS) reports an improvement of symptoms after apitherapy. The nurse knows that apitherapy falls under which category of treatment?

Biologically based practices

The nurse is caring for a client with hypertension and only documents a blood pressure of 170/100 Hg when all other vital signs are normal. This reflects what type of documentation?

Charting by Exception

A client with arthritis finds relief of pain in the practice of tai chi, acupuncture, and massage. The nurse understands this medical system approach to originate from which culture?

Chinese medicine

A client is having acute pain and tells the nurse that her pain has gradually reduced but that she fears it could reoccur and become chronic. What is a characteristic of chronic pain?

Chronic pain has far-reaching effects on the patient

Chloride

Cl-

A physician has ordered a nurse to administer conscious sedation to a client. What is possible after administering conscious sedation to a client?

Client can respond verbally despite physical immobility.

A client severely injured in a motor vehicle accident is rushed to the health care facility with severe head injuries and profuse loss of blood. Which sign indicates approaching death?

Client's breathing becomes noisy

When keeping a client's personal belongings in a locker, the nurse should ensure that the envelope is sealed and signed by which of the following people?

Client, supervisor and the nurse who listed the items.

When caring for a client, the nurse observes that the client enjoys reading books and magazines. In which of the following learning domains does the client's learning style fall?

Cognitive domain

The postanesthesia care unit (PACU) nurse has just received a client who underwent coronary artery bypass grafting (CABG). Which will the nurse assess while the client is in the PACU? (Select all that apply.)

Condition of incision Drains and drainage characteristics Ease of breathing Pain level Urine output

A nurse is caring for a client who is scheduled to undergo a mastectomy. Which major task does the nurse perform immediately during the preoperative period?

Conduct a comprehensive nursing assessment.

The nurse is caring for an elderly client with a persistent, dry cough. Which of the following would be the result if this persistent, dry cough is not treated quickly?

Consumes the client's energy

A Spanish-speaking client is admitted to the Emergency Department with a urinary tract infection and is experiencing a stress response from hospitalization. What is the priority nursing intervention?

Contact a translator.

A nurse is caring for a patient who has undergone a surgical intervention in which the pain pathways in the spinal cord have been interrupted to control his back pain. The nurse knows that the client has undergone which treatment?

Cordotomy

The nurse is required to provide formal education to a client admitted to the health care facility. Which of the following should the nurse consider first when providing formal education?

Creating a plan

A nurse is manually documenting information related to a client's condition. When documenting this information, the nurse makes an error on the manual record sheet. What is the best technique for recording the error made in documentation?

Cross out the incorrect statement with a single line and place nurse's initials above it.

A middle-aged man is reporting acute joint pain to a nurse who is assessing the patient's pain while at the pain clinic. Which question related to pain assessment should the nurse ask the client?

Does your pain level change after taking your analgesics?

A nurse is caring for a client who has been wrapped with antiembolism stockings to avoid thrombus formation. Which measure can prevent thrombi?

Drink plenty of fluids.

Hypervolemia might result in the following: Select all that apply.

Edema Hypertension

A nurse is teaching the importance of personal hygiene and proper bowel movement to a group of clients using gerogogy. Which client is the nurse addressing?

Elderly people

A male client is scheduled to have a suprapubic catheter inserted as part of his treatment for prostate cancer. The nurse is explaining the preoperative preparation that will be necessary, including hair removal. Hair removal will be accomplished with:

Electric Clippers

A client visits the health clinic with a report of slight chest discomfort. Which test should the client undergo to determine the possible cause of the discomfort?

Electrocardiogram

A nurse is caring for an older adult client who has been prescribed fluid restriction before surgery. What should the nurse check most carefully to assess the risks of fluid restriction in older adult clients?

Electrolyte levels

A client loses consciousness after strenuous exercise and need to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the patient is in need of the restoration of:

Electrolytes

A family has lost a member who was treated for leukemia at a nursing unit. The nurse provides emotional support to the family and counsels them to cope with their loss. Which quality should the nurse use in this situation?

Empathy

A nurse is caring for a terminally ill client whose death is imminent. The nurse has developed a close relationship with the family. Which intervention is most appropriate?

Encourage family discussions of feelings when appropriate.

An elderly client is dying in the hospital and has had few visitors because he is estranged from his children. While the nurse is providing his morning hygiene, the client states, "If I had it to do all over again, I'd do a lot of things differently." How should the nurse react to this client's admission?

Encourage the client to elaborate and listen carefully.

The nurse is caring for the same client this week and cared for the client the week before. Continuity of care is the process in which the client and the care team are involved in ongoing healthcare management. What is it important to continue with continuity of care?

Ensuring quality of care over time and ensuring that care is provided in the most appropriate and correct manner.

The nurse finds that she must choose between two undesirable alternatives involving a client that she is caring for. The client wants to be told about his prognosis, and the family member does not want the client to know. What type of situation does the nurse understand she is in?

Ethical dilemma

Certain dissolved substances require the assistance of a carrier molecule

Facilitated Diffusion

The nurse is working for a physician who participates in an HMO and will be assisting with the billing. What type of information regarding capitation does the nurse need to understand?

Fees are not based on the number of services provided but rather are projected to the number of participants and expected services.

A client had a total knee replacement performed 3 days ago and is now preparing for discharge home. What discharge teaching should the nurse provide to this client? (Select all that apply.)

Guidelines for safely resuming normal activities Potential side effects of prescribed medications Information about the signs and symptoms of infection Information about follow-up appointments that may be required

Bicarbonate

HCO3-

A client has come to a health care facility for autologous donation of blood. Which is a criterion for autologous donation?

Have a physician's recommendation.

What does the nurse understand is the focus of healthcare when a client receives services from a health maintenance organization (HMO)?

Health promotion and maintenance

Which nursing intervention reflects culturally appropriate care when caring for a female Latino client?

Include the client's spouse in decision-making, if the client desires.

A nurse is caring for a visually impaired client. How should the nurse manage the feeding of this client?

Inform the client what kind of food is being offered with each mouthful of food.

A nurse finds that a colleague is intoxicated while on duty. What appropriate action should the nurse take?

Inform the nursing supervisor.

An HIV-positive client discovers that his name is published in a research report on HIV care prepared by his nurse. He is hurt and files a lawsuit against her. Which offense has the nurse committed?

Invasion of privacy

A nurse is preparing a client for endotracheal intubation. The anesthesiologist has ordered an anticholinergic medication for this client. What is an action of this medication

It decreases respiratory secretions

The nurse is teaching a client who will undergo abdominal surgery to repair a hernia about deep breathing. When the client asks, "Why am I practicing breathing when I'm having hernia surgery", what is the appropriate nursing response?

It decreases the post operative risk for respiratory complications

A nurse is assisting a physician during a cesarean section for a client. The client is administered epidural anesthesia. What is an advantage of epidural anesthesia?

It decreases the risk of gastrointestinal complications.

A nurse is dressing the wound of a client who is admitted to the outpatient surgical unit. What is a major advantage of outpatient surgery?

It interferes less with the client's daily routine.

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation?

It list expected normal parameters and provided quick access to abnormal findings.

A client informs the nurse that he wants to discontinue his treatment and go home. Later, the nurse finds the client dressed to leave. Which action should the nurse take in this situation?

Let the client go after signing a document stating he is going against medical advice.

A nurse is taking care of a client during the immediate postoperative period. Which duty performed during the immediate postoperative period is most important?

Monitor the client for complications.

A client has been diagnosed with a terminal illness and has periods of depression and periods of anger. The client's spouse is concerned, feeling as though their loved on is not moving forward in the stages of grief. What teaching is most appropriate for the nurse to include? (Select all that apply.)

Movement back and forth between stages is expected Movement between stages can be progressive

A client who has been diagnosed with Diabetes Mellitus must monitor her Carbohydrate intake. Which statement requires addition instruction to the client regarding diet therapy?

My favorite drink is coffee with 3 packs of pure sugar each morning.

The nurse is teaching a client who will undergo an electroencephalogram. Which client statement reflects that teaching has been completed and was effective?

My healthcare provider will tell me whether I should withhold my schedule medications.

The hospital is having a problem with healthcare-associated infections. A committee has been established to study the problem and make recommendations. The nurse working on the committee knows that this work addresses what?

National Patient Safety Goals

A client who is a drug addict visits a health care facility for treatment. During counseling, he discloses that he took to drugs because it helped him deal with stressful situations. The nurse explains that he is not using the correct coping strategy to overcome his stress-related problems. What kind of strategy has the client used in this case?

Nontherapeutic coping strategy

A nurse is working with a client who is in postoperative day 2 following a total knee replacement. The client has briefly mobilized using a wheeled walker and with the assistance of the physical therapist. However, the client is reluctant to progress further with mobilization for fear of injuring herself. In response to this, the nurse converses with the physical therapist to create a plan of care that creates specific goals for the client's mobility. In doing so, this nurse has exemplified what role?

Nurse as collaborator

A group of nursing students are reviewing the ANA's current code of ethics. A code of ethics is important in the nursing profession because:

Nursing practice involves numerous interactions between laws and individual values.

A nurse is providing health education to a client who has been admitted to the health care facility. How can the nurse best determine that the education standards have been met?

Observe changes in the client's behavior after teaching.

An older adult client with dehydration repeatedly tells the nurse, "I am not thirsty." I don't want anything to drink." What is the appropriate nursing action? (Select all that apply)

Offer fluids to the patient at times other than meals Identify fluid preferences Offer small amounts of preferred liquids frequently

The nurse is caring for a client who is undergoing a myelogram which involves the injection of contrast medium. The client expresses to the nurse, "I am afraid that this will hurt." What is the appropriate nursing response?

Offer to stay with the client and provide empathy.

A nurse at a health care facility uses a tonsil-tip catheter to remove the secretions from the mouth of a client with chest congestion. Which suctioning technique is the nurse using in this case?

Oral suctioning

A 22-year-old woman who recently emigrated from Laos has been admitted to the hospital with an ovarian cyst. Both the client and her husband speak Lao exclusively and this has complicated the ability of the care team to obtain informed consent for surgery. What action should the care team take in order to communicate with the client?

Organize professional interpretation, either in person or by telephone.

A nurse is caring for a client who has taken an overdose of ibuprofen. Which tube is most suitable for removing the toxic substances?

Orogastric Tube

The nurse is caring for a client who just underwent an esophagealgastroduodenal endoscopy (EGD). Which assessment finding requires immediate intervention?

Oxygen Saturation of 90%

The nurse has provided teaching for a client with a sinus infection who has been prescribed antibiotics and a decongestant. What is the appropriate nursing response when the client states, "I'm not sure how many days I'm supposed to take this antibiotic."

Re-teach the length of time to take the prescription.

What is the primary reason the nurse needs to ascertain client use of vitamins and minerals and the dosage of each?

Recommended daily allowance (RDA) for each vitamin and mineral may vary with special populations.

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, assessment findings, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nurse implementing?

SOAP charting

A client visits the medical unit with the client's father for a scheduled checkup. The client's father has been recently diagnosed with hypertension. The nurse suggests that the client get his blood pressure regularly checked to avoid possible problems. What level of prevention is the nurse following in this case?

Secondary level

A nurse is caring for a patient who was administered opioid narcotics. The client reports constipation. What is another potential side effect of opioid narcotics?

Sedation

A client visits a health care facility reporting work-related stress that alters his mood when he comes home. The nurse suggests that the client make changes to his home décor to include vibrant colors and bright lighting, and listen to soothing music when he returns home. Which stress-reducing technique is the nurse following in this case?

Sensory manipulation technique

When conducting health teaching for a client, the nurse uses the client's name frequently throughout the instructional period. Which learning barrier is the nurse trying to resolve?

Shortened attention span

The nurse is caring for a patient who has arthritis of lower extremities and is difficult to move. The patient needs an enema (fluid through the rectum). Which position should the nurse ask the client to maintain during the administration?

Sim's

A client with persistent nausea is diagnosed with somatization. What is the appropriate nursing action when the client reports nausea?

Sit with the client and ask them about their feelings.

A client has a diagnosis of stage 4 Non-Cell Small Lung Cancer. The nurse who works in acute care consulted social services for discharge planning regarding the appropriate level of care needed after chemotherapy. The client is able to provide partial self-care and will need pain medication. What setting is most appropriate for the client.

Skilled Care facility

An elderly client with a tracheostomy is to be discharged from a healthcare facility. Which of the following extended care facilities should the nurse suggest to the client for continued care until complete recovery?

Skilled Nursing facility

A client who is scheduled for hernioplasty needs clarification regarding the procedure. The nurse calls the physician at the client's insistence. The physician, who is in a bad mood, is overheard telling the client that the nurse does not know anything. Which legal tort has the physician committed?

Slander

A nurse, while off-duty, tells the physiotherapist that a client who was admitted to the nursing unit contracted AIDS at the age of 18. The client discovers that the nurse has revealed the information to the physiotherapist, and learns that the nurse wrongfully attributed the disease to the client's history of heroin addiction. With what legal action could the nurse be charged?

Slander

A nurse is assessing the nasal passages of a client before inserting the Nasointestinal tube. Which observation excludes nostril use for tube insertion?

Small growths of Tissue

While caring for a client with chronic pain, the nurse talks with a family member. Which family member statement is consistent with caregiver role strain?

Sometimes it seems like I can never get a moment to myself.

The nurse understands that offering chaplain services in the acute care facility supports which healing concept?

Spiritual healing

A client with fibromyalgia is using magnets as a form of complementary treatment. Which rationale given by the nurse best explains the physiologic principle of this technique?

Stimulates the release of endorphins

A client is dying of brain tumor but has maintained her level of consciousness and cognition, even as death is now imminent. The client's physical condition has deteriorated significantly over the past 48 hours and she adamantly states that she no longer wishes to eat. How should the care team respond to the client's statement?

Stop trying to feed the client

A nurse is caring for a terminally ill client with inadequate fluid volume. Which of the following actions represents one of the last reflexes to disappear as death approaches?

Sucking on wrapped ice cubes

A patient who has a fluid imbalance resulting in a fluid deficit might have the following signs:

Sunken Eyeballs Dry, sticky membranes Low Blood Pressure Scant, dark Urine

A nurse is caring for a pregnant client with multiple fetus' who is experiencing severe complications related to the pregnancy. Which view would a teleologist have in such a situation?

Support the procedure of selective abortion.

A general contractor is discussing a problem with the nurse, he tells the nurse that he is always doing small, petty jobs for everyone and he is not happy about this and it is not fulfilling. Because of this, he is feeling stressed and has been getting into fights with his wife. What should the nurse suggest to help the client overcome this problem?

Take control of the situation by changing his work options.

A client is discussing vitamin and mineral intake with the nurse. Which client statement requires education about the intake of vitamins?

Taking mega doses of vitamins will help me increase muscle mass quickly.

A nurse witnesses a traffic accident in which a child is badly hurt. The nurse dresses the open wounds sustained by the child. The family tries to give monetary compensation, which the nurse refuses. Later, in the hospital, the child develops complications due to infection in the wound. The family holds the nurse responsible for the complications and wants to file a lawsuit. Which of the following statements is true regarding the Good Samaritan law?

The Good Samaritan law will provide legal immunity to the nurse.

A physician directs the nurse to get written consent from a client who is to undergo multiple diagnostic examinations. As a rule, the written consent must confirm that the client understands the tests and will undergo them voluntarily. What else is necessary to make the client's written consent valid?

The client must be able to make rational decisions before any diagnostics.

Which of the following statements is applicable when a competent client wants to leave a hospital or long-term care facility before being discharged by the physician?

The client signs a form releasing the health care facility from its responsibility.

A client is admitted with symptoms of psychosis. The nurse hurries to the client's room when she hears the client calling for help. She finds the client lying on the ground. The nurse assists the client back to the bed and performs a thorough assessment. The nurse informs the physician and completes the incident report. Which statement should the nurse document in the incident report?

The client was found lying on the floor.

A client has been admitted to the health care facility and a plan of nursing care has been created. The nursing care plan specifies that client education should begin as soon as possible and a nurse has begun an assessment in preparation for this education. What assessment parameter should the nurse prioritize during this assessment?

The client's motivation to learn

A 7-year-old child is admitted to a health care facility. His parents explain that the child is not able to interpret what they say and so is not able to speak clearly. The child is also not able to remember anything he is taught in school. What should the nurse conclude about the part of the brain that is affected in this case?

The cortex is affected.

A nurse is determining the length of a nasogastric tube before insertion. The nurse is placing the distal tip of the tube at the client's nose. To which locations should the nurse measure for distance to ensure proper placement.

The ear and then to the xiphoid process

A group of nurses who work at a large, long-term care facility have become embroiled in controversy over a large number of residents who are refusing a seasonal influenza vaccination. Specifically, there is controversy around the appropriate amount of influence that nurses can exercise when encouraging residents to become immunized. A teleological perspective on this issue would prioritize what consideration?

The greatest good for the greatest number

A nurse is performing an admission assessment of a client who has multiple health problems, including a history of respiratory disease. The nurse is aware of the priority of airway management in this client. How is airway management best defined?

The maintenance of natural or artificial airways for compromised clients

A nurse is aware that clear and accurate communication is necessary whenever clients are transferred or referred. Which situation demonstrates a referral?

The nurse arranges for a client with an ulcer to see a podiatrist in the community.

The nurse has been fired from her job at the nursing home and reported to the state board of nursing for giving medication to a client without a physician's order. The nurse states that she was not aware that this was a violation of scope of practice. What is the nurse's responsibility regarding knowing how to practice within their scope?

The nurse should access her state nurse practice act to determine the set standard for nurses in her state.

A nurse is caring for a patient with cancer who is experiencing pain. What would be the most appropriate assessment of the client's pain?

The patient's recent responses to pain and pain medication

A nurse is working with an adult client who has been admitted with hyperglycemia following a period of poor glycemic control. The nurse has many similarities to the client with regard to age, gender, and socioeconomic status but is careful to utilize therapeutic communication techniques rather than social communication. How does therapeutic communication differ from social communication?

Therapeutic communication is focused on a particular goal while social communication is more superficial in content.

The client is admitted to the healthcare facility for minor surgery and is given a booklet by the nurse. Which of the following is a purpose of this booklet?

To orient the client to the facility

A nurse is assisting a physician in placing a tube inside a client with the help of an endoscope to provide access to various parts of the GI tract. Which tube is being inserted inside the client?

Transabdominal

A nurse is caring for a patient who injured cells are releasing chemical such as substance P, Prostaglandins, Bradykinin, histamine, and glutamate. Which phase of pain is the patient experiencing?

Transduction

The client who will undergo a radionuclide imaging test, asks the nurse if she can be sexually active after the procedure. What is the appropriate nursing response?

Use an effective contraception for a short period of time, during which radiation continues to be in your system.

A nurse needs to complete an assessment and vital signs on a client who has Alzheimer's disease. How should the nurse approach this client to gain cooperation? (Select all that apply.)

Use the client's name. Smile and maintain eye contact. Approach the client from the front.

When caring for a client at a health care facility, the nurse discovers that the client is unable to read or write. Which of the following teaching approaches is most useful for the client?

Use verbal and visual modes of communication.

A nurse is caring for a client who has a dull ache in the abdomen. On the way to the health care facility, the client vomits and shows symptoms of pallor. What kind of pain is the patient experiencing?

Visceral

A client who is post - operative from having bowel surgery is eager to eat. His family wants to bring in his favorite foods. The client is on a clear liquid diet. What food item is currently acceptable within this diet?

Weak Black Tea

A 17-year-old client who lives with her parents wishes to have a breast reduction. Which information will the nurse provide to the client?

You can sign the consent on this line. Your parent or legal guardian must sign the consent.

A terminally ill client at a health care facility has been referred for hospice care. Which client is eligible for hospice care?

a client with less than 6 months to live

The nurse is caring for a client who has been admitted for a new diagnosis of hypertension. When does the nurse begin client teaching?

as soon as possible after admission

The nurse is planning to provide teaching to a client who is recovering from abdominal surgery. When in the most appropriate time to teach the client?

as the client is sitting quietly, reading a book

A nurse is caring for an elderly client with muscle atrophy. Which condition can lead to muscle atrophy in elderly clients?

being bedridden for 1 or 2 days

The nurse is caring for a client who had an outpatient procedure. Which assessment finding indicates to the nurse that the client may be ready for discharge to home?

blood pressure 118/70 mm Hg, respirations 18 breaths per minute

Which action made by the nurse provides the best assessment data for presence of jaundice?

checking the hard palate

The nurse is creating a plan of care for a client with ineffective airway clearance related to a weak, persistent cough. What expected outcome will the nurse identify for the client?

clear airway as evidenced by clear lung sounds by Friday

A nurse at a health care facility is caring for a client who requires an artificial airway. The nurse could use an oral airway for which client?

client who is recovering from general anesthesia

The nurse is preparing discharge teaching for a client with diabetes. Which information will the nurse include? (Select all that apply.)

community resources for diabetic individuals appropriate use of glucometer instructions to follow-up with the healthcare provider meal planning

One of the nursing achievements in the Crimean War was that the death rate of soldiers dropped from 60% to 1%. What is the most appropriate reason for the fall in the death rate?

decreased rate of infection and gangrene

A nurse is caring for a client with a sinus infection at a health care facility. The physician has prescribed aerosol therapy to keep the mucous membranes moist and the mucus thin. What is a benefit of using aerosol therapy?

encourages spontaneous coughing

Regulates the movement of water and substances from a compartment where the pressure is higher to where the pressure is lower

filtration

A nurse is assessing the preoperative checklist of a client. Which observation listed in the preoperative checklist should the nurse verify?

if the client has worn dentures

A nurse is completing the preoperative checklist of a client who will soon have a cholecystectomy (gallbladder removal). Which observation listed in the preoperative checklist should the nurse verify?

if the client's allergies have been identified and documented

The nurse is caring for a client who is prescribed an antibiotic by mouth every 4 hours. When will the nurse document that the antibiotic has been given?

immediately following administration

Which nursing intervention reflects practice according to Madeline Leininger's transcultural nursing theory?

incorporating client's request for complementary treatment therapy

A nurse is called to a deposition for a malpractice charge that has resulted in the death of a client. As the chart is reviewed, the prosecuting attorney questions the nurse about several defaming comments written in the medical record about the client. What charges can be filed against the nurse due to these comments?

libel

A nurse who is infected with human immunodeficiency virus (HIV) accidentally gets a cut while debriding a wound, exposing the client to possible HIV infection. Failure of the nurse to report this incident violates which ethical principles? (Select all that apply.)

nonmaleficence veracity fidelity

The nurse is assigned to care for an elderly woman from India. As the nurse attempts to obtain vital signs, the client pulls away, gathers covers to the chin, and speaks in a language unintelligible to the nurse. What is the best action for the nurse to take?

obtain an interpreter to explain the procedure to the client

Water moves from through a semipermeable membrane from an area where the fluid is more dilute (less solute) to an area where the fluid is more concentrated (more solute concentrate)

osmosis

Movement of substances from an area of higher to lower concentration and does not require energy

passive diffusion

A nurse who works in a large, urban hospital provides care for a diverse client population. When performing integumentary (skin) assessments, the nurse modifies assessment practices for certain clients in order to identify clinically meaningful data. This practice is most justified by the fact that clients differ according to:

race

A nurse is working with a client whose quality of life is impacted by the presence of numerous health problems. The nurse is aware that the client's body is attempting to maintain homeostasis, a process that primarily involves:

responding appropriately to internal and external influences.

A nurse is applying for professional liability insurance. The nurse knows that professional liability insurance is important for which reason?

to retain legal representation that defends the nurse exclusively