3040 PrepU final exam

A nurse working in a facility that cares for clients with Alzheimer's includes spirituality in client care. A family caregiver tells the nurse that faith has been broken and asks about help in getting through the day. What approaches can the nurse use to help the family member? Select all that apply.

-Help the family member get relief so church services can be attended -Contact the family church group members for assistance -Give the family member some spiritual reading materials

The nurse has just successfully inserted an intravenous (IV) catheter and initiated IV fluids. Which items should the nurse document? Select all that apply.

-Location of the IV catheter access -Client's reaction to the procedure -Type of IV solution -Gauge and length of the IV catheter -Rate of the IV solution

According to Shelly and Fish (1988), which of the following are spiritual needs underlying all religious traditions that are common to all people? Select all that apply.

-Meaning and purpose -Love and relatedness -Forgiveness

The nurse is caring for a 3-year-old girl who is hospitalized following repair of a fractured femur. The child's parents have asked that the hospital chaplain visit this Sunday. Based on the child's developmental stage, what activities would be appropriate during the chaplain's visit? Select all that apply.

-Recitation of a simple prayer -Singing church hymns -Drawing pictures of religious figures

The nurse is discussing contraception with an adolescent client who asks the nurse: "What if I can't have an orgasm?" What is the nurse's best response?

"A mature sexual relationship does not require a man and woman to achieve simultaneous orgasm."

How would the nurse respond to a female client who says, "I do not think I have ever experienced an orgasm. Is that normal?

"A normal sexual response for women may include multiple plateaus without an orgasm as a result."

A client scheduled for outpatient surgery is requesting that the operating room be sprayed with holy water. Which is an appropriate response?

"Are you concerned how the surgery will go?"

A client has been receiving dialysis for years and now states, "I have been thinking about this for a long time. I no longer wish to continue dialysis. I just want to die." What is the most appropriate statement by the nurse?

"Can you tell me about why you've made this decision?"

Which question would be appropriate for the F in the FICA spiritual assessment tool?

"Do you consider yourself a spiritual person?"

A question that would be appropriate for the E in the HOPE spiritual assessment tool would be:

"Do you have a living will?"

The nurse is assessing a 27-year-old Navajo male who is being admitted for surgery. The client requests a visit from the spiritual healer. Which is the best response from the nurse?

"Do you have a preference as to which spiritual leader you would like to visit?"

A male client presents to the clinic with reports of erectile dysfunction. Which statement by the nurse will assist in identifying the potential cause of the erectile dysfunction?

"Do you take any medications such as antihypertensives, antidepressants, or illicit drugs?"

The community health nurse wants to identify clients who have lifestyle factors that may place them at risk for sensory disturbances. Which question will the nurse ask?

"Do you work around loud noises at work?"

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response?

"Fluid in the tissue space between and around cells."

A 16-year-old girl tells the nurse that her friend has genital warts and asks the nurse how to make sure that she does not get them. Which of the following should the nurse recommend?

"Get the human papillomavirus vaccine."

A client presents to the office with concerns of low testosterone and feels it is due to a pituitary gland disorder. Which teaching would the nurse provide to educate this client on how testosterone is produced?

"Gonads are the reproductive organs of the male and are responsible for the production of testosterone and spermatozoa."

The oncology nurse is caring for a client receiving chemotherapy. Which of the following statements would be a priority assessment for the nurse?

"Have you been experiencing any strange tastes or aftertastes lately?"

A nurse is caring for a client whose spouse died more than 4 years ago. What assessment question will the nurse ask to determine if the client is experiencing abnormal grief?

"Have you gone through and donated your spouse's clothing?"

While conducting a sexual history, the nurse asks a client about protection from sexually transmitted infections (STIs). Which question would be most appropriate for the nurse to ask?

"Have you had any sexually transmitted infections and if so, which ones?"

Which assessment question is most likely to yield data about a female client's sexual identity?

"How do you feel about yourself as a woman?"

A nurse is conducting a health history on a 45-year-old client. The nurse is preparing to address the client's sexual history. Which statement by the nurse would be most appropriate at this time?

"I am going to ask you some questions about your sexual health."

The nurse is providing education about barrier contraceptives. Which statement by the client indicates a need for further education?

"I can leave my diaphragm in for up to 48 hours."

When reviewing a client's chart, the nurse notes that the client is in the disorganization stage of grief. Which assessment finding would support this diagnosis?

"I feel like I have absolutely no idea what to do next."

A nurse is collecting a sexual health history from an older adult woman who is postmenopausal. Which client statement requires further education by the nurse?

"I have noticed I have less lubrication with sexual intercourse."

A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration?

"I should drink 2,500 mL/day of fluid."

A client with end-stage chronic obstructive pulmonary disease (COPD) has reached the end of the 6-month period for hospice services and the family caregiver states, "I don't know what we will do if they cut off our hospice services." What is the best response by the hospice nurse?

"I will contact the health care provider to extend services since your family member meets the criteria."

The nurse is talking with the family after their loved one died. What words of support and comfort would be most therapeutic for the nurse to say after this event?

"I would like to sit here with you and listen."

A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause?

"I've been taking antacids almost every 2 hours over the past several days."

A nurse has just finished a presentation on hospice and palliative care. Which statement by a participant would indicate a need for further education?

"In hospice care, the nurses make most of the care decisions for the clients."

A client who has suffered a debilitating stroke asks the nurse, "Why did God allow this to happen to me?" What question would the nurse ask to promote a conversation with the client about the client's spiritual needs?

"In the past, what has given you strength during a crisis?"

A nurse expresses a desire to become culturally competent in the care of females from Africa after a mission trip to the continent. Which statement by the nurse demonstrates an understanding of this population of clients?

"Infibulation is the narrowing of the vaginal opening through the creation of a covering seal."

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."

The nurse is trying to help the client cope with the dying process. Which nursing statement is most appropriate?

"It must be very difficult for you."

The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response?

"Let me refer you to the blood bank so they can provide you with information."

A gerontology nurse is discussing sexual dysfunction with an older adult male client. The nurse determines that the education has been effective when the client states:

"Malnutrition may cause impotence."

A teenage female client tells the nurse that she is having intercourse with her boyfriend. The client asks the nurse about methods to prevent pregnancy. Which statement by the nurse would be most accurate?

"Many unintended pregnancies result from the use of less effective methods of contraception."

A client diagnosed with a terminal illness is displaying periods of depression and anger alternating with acceptance. The client's spouse is concerned about the client's labile mood. When talking with the client's spouse, which statement made by the nurse best addresses principles of loss and grieving?

"Not everyone experiences grief in the same way and your loved one needs our support."

Which client statement most clearly suggests the potential of a nursing diagnosis of Spiritual Anxiety?

"Now that I'm nearing the end, I'm worried that God won't think I lived a good enough life."

A nurse reads in a client's chart that he or she has gender dysphoria. The nurse determines that the client understands the diagnosis when making what statement?

"People whose biologic sex at birth is contrary to the gender they identify with have gender dysphoria."

The nurse is caring for a client who recently lost an older adult parent. Which client statement alerts the nurse that the stage of depression may have started within the grief process?

"Please go away; I just want to be left alone."

The student is explaining the factors affecting sensory stimulation to his professor. The professor knows that which of the student's statements is most accurate?

"Religious norms within a culture influence the amount of sensory stimulation a person seeks."

The nurse has provided information to a client about oral contraceptives. Which statement by the client would indicate a need for further education?

"Some oral contraceptives protect against STIs."

The nurse is caring for a client who recently found out he has a terminal illness. The nurse notes that the client is hostile and yelling. Which statement by the nurse shows that she has understanding of the Kübler-Ross emotional responses to impending death?

"Sometimes a person returns to a previous stage."

The nursing instructor has been discussing spirituality with a group of nursing students. Which statement by a student would indicate a need for further education?

"Spiritual beliefs and practices do not give strength when a person is in crisis."

Upon assessment, the client reports not belonging to an organized religion. Which assessment question would the nurse ask to assess the client's spirituality?

"Tell me about spiritual or religious beliefs that are important to you."

Which response will the nurse provide to a 13-year-old female client who says to the nurse, "My parents said masturbation is wrong. Is that true?"

"Tell me more about what you know of masturbation."

When preparing for palliative care with the dying client, the nurse should provide the family with which explanation?

"The goal of palliative care is to give clients the best quality of life by the aggressive management of symptoms."

"My father has been dead for over a year and my mother still can't talk about him without crying. Is that normal?" What is the best response by the nurse?

"The inability to talk about your dad without crying, even after a year, is still considered normal."

While teaching sexual education to a group of high school students, the nurse talks about forms of birth control and when a woman can become pregnant. Which explanation by the nurse about the chance of the woman becoming pregnant is accurate?

"The intrauterine device is a highly effective and reversible contraceptive."

A 17-year-old girl tells the nurse she uses tampons and asks how she can cut down on odor during her period. What is the nurse's best response?

"The tampon should be changed frequently."

Parent's of a 5-year-old child inform the nurse that they are concerned about finding their child masturbating in the bathroom. What is the best response to the parents by the nurse?

"This is a normal behavior for this age group, because 5-year-olds are increasingly aware of self."

When a client with end-stage renal failure states, "I am not ready to die," what is the appropriate nursing response?

"This must be very difficult for you."

The student nurse asks, "What is intravascular fluid?" What is the appropriate nursing response?

"Watery plasma, or serum, portion of blood."

The nurse is teaching a nursing student how to record strict I&O for a client who wears adult absorbent undergarments. Which nursing teaching is appropriate?

"Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)."

The nurse is providing care for a client that is terminally ill with cancer. The client states to the nurse, "Am I going to die?" What is the most therapeutic response by the nurse?

"What have you been told?"

An older adult client who is in a long-term care facility tells the nurse, "I am not eating that, it is poisoned." Which is the best way for the nurse to address the client's statement?

"What makes you think the food is poisoned?"

A middle-aged male client is in the clinic for a routine blood pressure check. During the health history, the client mentions to the nurse about being concerned that the spouse is "unhappy with their love life." Which question is best for the nurse to ask?

"What makes you think your spouse is unhappy? What has happened?"

The nurse overhears a client, who is scheduled to begin chemotherapy, tell a family member that everything will eventually be okay and the cancer will be in remission. Which question will the nurse ask to begin a conversation about hope with the client?

"What provides you with strength to deal with this health situation?"

The nurse assessing an adolescent's need for further information regarding sexual health should ask which question?

"What questions or concerns do you have about your sexual health?"

The nurse is caring for a critically ill client who informs the nurse that there is a conflict between the client's spiritual beliefs and a proposed health option. Which question does the nurse ask to begin a conversation about the conflict that the client is experiencing?

"Would you like to talk to someone to help you make an informed decision?"

An adolescent female client expresses concern to the nurse about her anatomy looking "weird down there." Which response(s) by the nurse is appropriate? Select all that apply.

- "Tell me more about the concerns you have about your body." - "You may want to try using a mirror to better see and understand your anatomy." - "Explain what you mean when you say you look's weird down there.'"

The nurse is caring for Nancy, a 45-year-old client with diabetes mellitus. She has severe neuropathy and consequently has little or no feeling in her feet and lower legs. The nurse includes which nursing interventions in the care plan related to this lack of tactile sensation? Select all that apply.

- Assess for shoe type and correct fit. - Educate client to never go barefoot. - Protect skin from temperature extremes. - Perform frequent, thorough skin assessments.

The nurse is teaching a group of clients about general eye care to prevent vision loss and eye injury. What will the nurse include in the presentation? Select all that apply.

- Avoid eye damage from ultraviolet rays. - Use caution with corrosive agents. - Avoid eye strain and rubbing eyes. - Wear protective goggles for mowing lawns.

The nurse is caring for an older adult client that recently lost total vision in both eyes due to macular degeneration. Which interventions will the nurse add to the client's plan of care to assist with the with vision loss? Choose all that apply.

- Clear the room of clutter and do not rearrange furnishings. - Orient to sounds in the immediate environment. - Inform the client when the nurse is leaving the room - Acknowledge presence when entering the room.

A nurse is caring for a client who requires intravenous (IV) therapy. The nurse understands that which actions are the nurse's responsibilities related to this therapy? Select all that apply.

- Deciding the location of the IV catheter. - Deciding the size of the IV catheter. - Administering the IV solution.

A nurse is paying particular attention to the spiritual needs of a client today. The nurse identifies that spiritual beliefs can have a positive effect on general health of a client in which ways? Select all that apply.

- Diet -Support system -Endurance of extreme stress -positive emotions

The nurse is caring for a client at risk for the development of cognitive impairment related to a spinal cord injury. When creating the plan of care for this client, what interventions should the nurse include to avoid this development? Select all that apply.

- Discuss current events or the client's occupation, hobbies, or interests. - Have the client assist in self-care as much as possible. - Orient the client to the surroundings and environment every 1 to 2 hours.

The nurse is caring for a client at risk for the development of cognitive impairment related to a spinal cord injury. When creating the plan of care for this client, what interventions should the nurse include to avoid this development? Select all that apply..

- Discuss current events or the client's occupation, hobbies, or interests. - Have the client assist in self-care as much as possible. - Orient the client to the surroundings and environment every 1 to 2 hours.

The nurse is caring for Mr. Cantrell, a 69-year-old client. He has gradually lost much of the ability to hear in both ears due to working with loud machinery all of his working life. Which interventions will the nurse add to Mr. Cantrell's care plan in order to make him more comfortable with his hearing loss? Choose all that apply.

- Face the client; use meaningful gestures. - Be aware of nonverbal communication. - Decrease background noise if possible. - Do not chew gum or food when speaking.

The nurse is receiving a change of shift report on a client who has a terminal illness and has exhibited a slow and progressive decline in the health status over the past several days. Which data supports the client's impending death? Select all that apply.

- Gurgling sounds emanating from the client's throat with each breath - Distended abdomen with last bowel movement documented 7 days ago - Cyanotic nail beds in hands and feet bilaterally

When preparing for the death of a client, the nurse should provide the client's family with which interventions? Select all that apply.

- Listen to concerns, fears, and worries. - Encourage rest and proper nutrition. - Explain the dying process and allow grieving. - Utilize therapeutic communication techniques.

A nurse is conducting grief resolution for a client who lost his wife in a motor vehicle accident in which he was the driver. Which interventions best accomplish this goal? Select all that apply.

- Listen to expressions of grief. - Include significant others in discussions and decisions as appropriate. - Communicate acceptance of discussing the loss.

The nurse is caring for Emily, an 81-year-old client who is struggling to adapt to worsening vision as she ages. The nurse performs which interventions to assist Emily in adapting to this sensory deficit? Choose all that apply.

- Make sure her glasses are available. - Provide adequate lighting. - Provide large print books.

When assessing a person who is grieving using the grief cycle model, which concept would be most important for the nurse to keep in mind? Select all that apply.

- People vary widely in their responses to loss. - Stages occur at varying rates among people. - Some people actually skip some stages of grief altogether.

The nurse is working at a pediatric clinic when Mrs. Karlilse comes in with her toddler and two preschoolers. She is distraught and tells the nurse she wants her children to just sit quietly and look at books or take naps. Instead, she says the children play noisily and scatter toys throughout the house. She indicates that she loves her children, but does not understand the need for the loud activities. To provide correct education, the nurse's best response about appropriate play for the children includes which of the following? Select all that apply.

- Play assists in learning gender roles. - Play develops muscles and coordination. - Play is an outlet for physical and emotional energy. - Play develops social skills and self-insights.

The student nurse is preparing a presentation on sensory perception. What symptoms of sensory deprivation should the student include? Select all that apply.

- Sleeplessness - Decreased interest in activities - Depression

A client who was admitted to the critical care unit is experiencing sensory overload. When developing this client's plan of care, which intervention would be appropriate for the nurse to include? Select all that apply

- Suggest the use of noise-reducing headphones or ear plugs. - Offer simple explanations before a treatment or procedure. - Set up a consistent schedule for routine care activities.

A client who was admitted to the critical care unit is experiencing sensory overload. When developing this client's plan of care, which intervention would be appropriate for the nurse to include? Select all that apply.

- Suggest the use of noise-reducing headphones or ear plugs. - Offer simple explanations before a treatment or procedure. - Set up a consistent schedule for routine care activities.

The oncology nurse is learning to care for dying clients. Which ideals should guide the nurse in facilitating a good death for these clients? Select all that apply.

- The characteristics of a good death vary for each client. - Independence and dignity are central issues for many dying clients.

A middle-aged female client visits the clinic to confirm pregnancy. "I cannot believe this is happening. I cannot be pregnant. My parents will kill me. I was raised in a strict Roman Catholic home. I was not supposed to get pregnant before marriage."

- The client is exhibiting signs of spiritual guilt - Related to the inability to live up to devout practices

The nurse prepares to discuss emergency contraception with a client who reportedly had unprotected sex the day before. What information should be covered when counseling the client? Select All That Apply

- The need to take oral contraceptives within 120 hours after intercourse. - Oral contraceptives are up to 89% effective in preventing pregnancy. - A copper intrauterine device (IUD) can be inserted five to seven days after sex.

Which are signs of a "good death"? Select all that apply.

- The person dies with dignity. - The person is prepared for death. - The person has a sense of completion of life.

The nursing instructor is discussing IV fluid overload with the nursing students. What will the nurse include in her discussion? Select all that apply.

- The use of packed cells instead of whole blood will decrease the fluid volume delivered to the client. - A symptom of fluid overload is distended neck veins. -Fluid overload is more likely in very young children. -The infusion rate must be carefully monitored during the administration of blood.

The nurse is caring for Mrs. Meld, a 62-year-old client with dementia who is confused. Which nursing interventions will the nurse include in Mrs. Meld's care plan to facilitate communication? Choose all that apply.

- Use frequent face-to-face contact. - Reorient the client to her environment as needed. - Speak calmly, simply, and directly. - Use clocks and calendars for orientation.

Which clients would the nurse identify that are at risk for the development or presence of sexual dysfunction? Select all that apply.

- a 30-year-old female experiencing PMS - a postmenopausal female client - a 52-year-old male with a history of hypertension

The student nurse is preparing a presentation on sensory perception. What symptoms of sensory deprivation should the student include? Select all that apply

- depression - Sleeplessness - Decreased interest in activities

When preparing the care plan for a dying client, it is important for the nurse to include a goal that addresses which needs? Select all that apply.

- expression of feelings - management of pain - use of coping strategies

A nurse reads a client's chart and sees that she may have dyspareunia. Which of the following would be priority assessments? Select all that apply.

- history of hormonal imbalance - client's ability to use vaginal lubricants during sexual act - physical assessment of internal and external genitalia

Which conditions occur in clients who are experiencing the effects of sensory deprivation? Select all that apply.

- inaccurate perception of sights, sounds, tastes, and smells - inability to control direction of thought content - difficulty with memory, problem solving, and task performance

The nurse is working on a neurological unit and must perform an assessment on a client for disturbed sensory perceptions. The nurse thinks about the human senses and knows that they must assess for which of the following? Select all that apply.

- medications that may alter sensations - anything interfering with sensory reception - any recent changes in sensory stimulation - use of assistive devices for senses

The nurse is working on a neurological unit and a physician asks the nurse to perform a sensory experience assessment for a client. The nurse thinks about what things may place a person at risk for disturbed sensory perception and comes up with which of the following? Select all that apply.

- neuropathy related to diabetes mellitus - medications that alter certain senses - diminished senses related to advanced age

A client with uncontrolled diabetes develops hypophosphatemia. Which finding would the nurse most likely assess? Select all that apply.

- respiratory muscle weakness - confusion - ventricular dysrhythmia

The nurse is teaching a male adolescent how to use a condom. Which teaching points would the nurse include? Select all that apply.

-"If the condom does not have a nipple receptacle, leave a small space at the end for semen to collect." -"Use a condom with every act of intercourse." -"Immediately after ejaculation remove the condom and discard it."

A nurse is conducting a spiritual assessment on a client recently admitted to the hospital unit. Which questions would be appropriate to ask the client about his religious and spiritual practices? Select all that apply.

-"Is religion a significant part of your life?" -"Are there any spiritual practices that you would like to continue while hospitalized?" -"Does the present situation interfere with any spiritual or religious practice?"

When conducting a spiritual assessment, the nurse must be sensitive to the client's personal beliefs. Which questions should the nurse ask? Select all that apply.

-"Is religion or God significant to you?" -"Do you feel your faith is helpful to you?" -"Is there anyone from your church you would like to talk to?"

The nurse admits a new client to the unit for elective surgery. What would be the best way for the nurse to facilitate the practice of religion for this client? Choose all that apply.

-Arrange for the client's pastor to visit if desired. -Attempt to meet religious dietary restrictions. -Respect the need for privacy during periods of prayer.

The nurse's client states that his pastor is coming in a few hours to pray with him and offer sacrament. The nurse plans to do the following things in preparation for this. Select all that apply.

-Clear the bedside table; cover with clean towel. -Have a chair available near the bed. -Clear the room of unnecessary items.

The nursing instructor is teaching about spirituality and asks a nursing student about the factors that can influence a client's spirituality. Which responses by the student are accurate? Select all that apply.

-Developmental considerations -Family -Ethnic background -Formal religion

The nurse understands that spiritual care is dynamic and embodies some of the basic tenets of nursing. What is a factor supporting this concept? Select all that apply.

-Therapeutic use of self -Client centeredness -Spiritual nurturing environment -Nurse's availability for the client

Which of the following accurately describes senses by which individuals maintain contact with the external environment? Select all that apply.

-Vision -Hearing -Smell -Taste

A nurse is conducting online research for information related to spiritual needs and religious traditions. The nurse demonstrates understanding of the information by identifying which need as common to all? Select all that apply.

-love -meaning -forgiveness

A nurse is educating staff members about the importance of meeting the spiritual needs of clients on the unit. What spiritual needs should be met in the delivery of care? Select all that apply.

-need for meaning and purpose -need for love and relatedness -need for forgiveness

The school nurse is providing health education about sexuality and reproduction to a group of young adolescents. The male sexual response is included in the teaching plan.

-penile circumference at the coronal ridge thickens -increased heart rate and blood pressure -secretion of pre-ejaculatory fluid

What commonly used intravenous solution is hypotonic?

0.45% NaCl

The nurse is preparing to counsel a couple on their sexual relationship. The nurse prepares for the session by reviewing the sexual response cycle. The nurse recalls the order of the four phases of the cycle. Place the phases in correct order as they occur. Use all options.

1 Excitement 2 Plateau 3 Orgasm 4 Resolution

A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells?

1 unit over 2 to 3 hours, no longer than 4 hours

The nurse is administering 1,000 mL 0.9 normal saline over 10 hours (set delivers 60 gtt/1 mL). Using the formula below, the flow rate would be: gtt/min = milliliters per hour x drop factor (gtt/mL) ÷ 60 min/hr

100 gtt/min

The nurse is assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade?

2+

The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend?

2,500 mL/day

A nurse is measuring the intake and output of a client who is dehydrated. What is the average adult daily fluid intake in milliliters that the nurse would use as a comparison?

2,600 mL

A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL?

3,000

The nurse calculates the client's intake and output for the shift (above). Calculate the client's fluid balance, in milliliters, for the 8-hour shift. Record your answer using a whole number.

410

The nurse is calculating the infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 8 hours, with gravity infusion. Your tubing delivers 20 gtt [drops]/1mL. What is the infusion rate?

42 gtt/min

A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/ml What is the flow rate?

50 gtt/min

Total parenteral nutrition is hypertonic. What is the percentage of dextrose in these solutions?

50% dextrose

A physician has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing?

60 drops/mL

A health care provider orders a bolus infusion of 250 mL of normal saline to run over 1 hour. The set delivers 20 gtt/mL. What is the flow rate in gtt/min?

83 gtt/min

The nurse is calculating an infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 12 hours using an electronic infusion device. What is the infusion rate?

83 mL/hr

Based on religious customs, for which client would the nurse administering medicines avoid touching the client's lips?

A Hindu client

Which situation demonstrates sensory adaptation?

A client has learned to sleep through the frequent beeping of the intravenous pump.

The nursing diagnosis Risk for Sensory Deprivation is best suited for which client?

A client whose room at the end of the hallway has the door closed most of the time

A client with protracted nausea and vomiting has been receiving intravenous solution at 125 ml/h for the past several hours. The administration of this solution has resulted in an increase in blood pressure because the water in the solution has passed through the semipermeable membrane of blood cells, causing them to swell. What type of solution has the client been receiving?

A hypotonic solution

Which assessment finding would best support a nursing diagnosis of Dysfunctional Grieving?

A man is unable to return to work after his sister's death 18 months ago.

Which is not a lifespan consideration for sensory perception?

A newborn's sensory perception is very refined.

The nurse is caring for a client that practices Islam in the hospital. When dietary brings the client a food tray for supper, which food on the tray should the nurse remove that is against the dietary laws for a practicing Muslim?

A pork chop

During a well-check visit of a toddler, the parent mentions that the child is exhibiting sexual behaviors. Which information on growth and development of a toddler will the nurse discuss with the parent?

Acknowledge that masturbation is normal.

An older adult client who identifies as a devout Catholic has recently relocated to an assisted living facility. The client is pleased with most aspects of the living situation but laments the fact that the church is not nearby, so attending daily mass is not an option. The client is quite upset by this restriction and states, "Going to daily mass was my life." Which action would the nurse take to address the client's spiritual distress?

Actively listen to the client to explore the client's feelings.

A client has newly diagnosed cirrhosis and has pulled his nasogastric (NG) tubing for the third time. His ammonia level is above normal. Which nursing diagnosis is appropriate for this client?

Acute Confusion

A client has responded to a recent diagnosis of lung cancer by making extensive plans for overseas travel with family, despite the extremely poor prognosis. The client is adamant about not discussing cancer and is identified by the nurse as experiencing the denial stage of grief. How can the nurse best facilitate the client's healthy grieving?

Address the client's diagnosis and prognosis at a later time or date.

Which priority intervention should the nurse plan to implement to reduce a client's discomfort during terminal weaning?

Administer sedation and analgesia.

Assisted suicide is expressly prohibited under statutory or common law in the overwhelming majority of states. Yet public support for physician-assisted suicide has resulted in a number of state ballot initiatives. The issue of assisted suicide is opposed by nursing and medical organizations as a violation of the ethical traditions of nursing and medicine. Which scenario would be an example of assisted suicide?

Administering a lethal dose of medication

The nurse is caring for a client who has just expired. Which action will the nurse perform?

Allow the client's family to see the client's body before it is discharged.

What is the initial purpose of the action in which the nurse is engaging, during the preparation for the administration of a prescribed IV solution?

Allowing for effective access to the solution

A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs?

An implanted central venous access device (CVAD)

The nurse takes into consideration factors that affect sensory stimulation in hospitalized clients when planning care. Which statement is true?

An individual's culture may dictate the amount of sensory stimulation considered normal.

A client states, "My children still need me. Why did I get cancer? I am only 30." This client is exhibiting which stage, according to Kübler-Ross?

Anger

The nurse is justified in assessing for sexual dysfunction among male clients who are receiving which of the following?

Antihypertensive medication

A client is dying and the nurse has developed a strong rapport with the client and spouse. The spouse states to the nurse, "I just don't know how I am going to deal with the process. It makes me nervous to think I can't deal with it." What is the priority concern with the spouse of the client?

Anxiety related to unknown reaction to stages of death

The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client?

Apply pressure to insertion site for at least 3 minutes.

What is the lab test commonly used in the assessment and treatment of acid-base balance?

Arterial blood gas

When reviewing the history of a client admitted to the health care facility, the nurse notes that the client reported being an atheist. Which action will the nurse take to meet spiritual needs when planning nursing care for the client?

Ask the client how he or she expresses spirituality.

A client self identifies as a member of the Jewish faith. When discussing diet and food preferences with the client, which assessment would be useful?

Ask the client what diet is followed at home.

An older adult client has been hospitalized for 8 days following skin grafting. The nurse suspects the client is experiencing sensory deprivation. Which strategy will be most effective in this situation?

Assess and reorient the client to time, place, and person as needed

The nurse receives a "do not resuscitate" (DNR) order for a dying client. What should the nurse do next?

Assess the client's spiritual needs

A nurse admitting an unconscious person to the unit considers which guideline when performing care for this client?

Assume the client can hear you, and talk with him or her in a normal tone of voice.

Which statement regarding perceptions of death by children is accurate?

At about age 9, the child perceives death as irreversible.

A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client?

Avoid salty or excessively sweet fluids.

The nurse cares for a client of the Islamic faith. Which lunch will the nurse recommend to the client?

Broiled chicken sandwich with skimmed milk

A graduate nurse enters a client's room and finds the client unresponsive, not breathing, and without a carotid pulse. The graduate nurse is aware that the client has mentioned that he does not wish to be resuscitated, but there is no DNR order on the client's chart. What is the nurse's best action?

Call a code and begin resuscitating the client.

The nurse recommends a barrier method of contraception for a client who is concerned about the side effects of hormonal contraception. Which method might the nurse suggest?

Cervical cap

A nurse is counseling a couple who expressed that they are having difficulty conceiving. What could the nurse consider as a cause?

Changing developmental stage

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 nurse is working with a student nurse on the surgical unit. The nurse should describe what benefit of providing health education before the procedure?

Clients are better able to handle new experiences.

In the female reproductive system, what corresponds with the male penis?

Clitoris

A client in a long-term care facility cannot control the direction of thought content, has a decreased attention span, and cannot concentrate. Which effect of sensory deprivation might the client be experiencing?

Cognitive response

A client brought to the emergency room is unconscious and cannot be aroused. The client is breathing and has a heartbeat. What state of awareness is this client exhibiting?

Coma

The nurse is caring for Jana Wok, a 23-year-old patient who suffered a traumatic brain injury in a motor vehicle accident. Jana requires mechanical ventilation, cannot be aroused, and displays no response to painful stimuli. The nurse documents that Jana's level of consciousness is which of the following?

Coma

A nurse is conducting a healthy living workshop with a group of female college students. Which information will the nurse include in the teaching plan about condoms?

Condoms can protect the client from pregnancy

The nurse is caring for a Roman catholic client who is dying. What would be an appropriate action for the nurse?

Contact a local priest to complete the anointing of the sick ritual.

The son of a dying female client is surprised at his mother's adamant request to meet with the hospital chaplain and has taken the nurse aside and said, "I don't think that's what she really wants. She's never been a religious person in the least." What is the nurse's best action in this situation?

Contact the chaplain to arrange a visit with the client.

A client has been declared brain dead following a fall from a roof. The client's advance directives state they do not wish to have prolonged life measures, and that only the heart, kidneys, and liver should be donated. The client's spouse wants to also donate the client's corneas. What is the appropriate nursing action?

Contact the organ procurement team to discuss organ donation with the spouse.

A female nurse is giving a complete bed bath to a young male client. The nurse notices the client has an erection. Which action will the nurse take?

Continue bathing the client.

The physician tells the nurse that the elderly client has presbycusis. Which of the following interventions will the nurse place in the client's care plan?

Decrease background noises, as much as possible, before speaking.

A client is immobilized following a traumatic amputation of both legs. When planning this client's care, the nurse would be alert for which factor that has the potential to contribute to sensory deprivation in this client?

Decreased environmental stimuli

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?

Decreased potassium levels

A hospitalized client refuses to eat because she fears that the kitchen personnel are poisoning her food. What is this client experiencing?

Delusions

The nurse has noted that a dying client is increasingly withdrawn and is often teary at various times during the day. The nurse recognizes that the client may be experiencing which of Kübler-Ross's stages of grief?

Depression

After teaching a staff development program about the major world religions and their view of health and illness, the nurse determines that the teaching was successful when the participants identify which statement as best reflective of Buddhism?

Dietary restrictions on some holy days.

The nurse is assuming care for a client who is receiving an infusion of packed red blood cells (PRBCs). The PRBCs were hung 4 hours ago, and 100 mL is left to infuse. Which action is most appropriate?

Discontinue the infusion and record the volume left in the blood bag.

A client has received morphine for reports of pain at a recent surgical incision site. After receiving the medication, the client starts picking at the bedsheets and saying, "Get the bugs off my bed, I can feel them crawling on me!" Which nursing diagnosis is appropriate for this client?

Disturbed Sensory Perception: Tactile related to side effects of medication as evidence by client statement of "Get the bugs off my bed, I can feel them crawling on me."

The nurse is providing care for a confused client who no longer is able to make health care decisions. Which document will the nurse review on the client's medical record to determine the designated person to make decisions on the client's behalf?

Durable power of attorney form

A woman age 49 years has sought care from her primary care provider because of "intimacy problems." Upon questioning, the woman reveals that she is experiencing sexual desire, but that intercourse causes her significant pain. In the absence of sexual activity, the woman states that she does not have any significant vaginal discomfort. What would the clinician recognize that this client is most likely experiencing?

Dyspareunia

The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome?

ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet.

The nurse assesses that her client has olfactory disturbances. Which of the following health topics would be important to teach the client?

Eliminating disturbing odors with adequate ventilation

The husband of a client with terminal cancer is afraid of hurting his wife during sexual intercourse. Which action by the nurse is likely to be most helpful in reducing this client's fears?

Encourage discussion between the husband and wife regarding their intimacy needs

The nurse is caring for a dying male client who practices Islam. What is the most appropriate action for the nurse after the client's death?

Ensure that a male washes the client's body.

A home health nurse notices that an older adult client the nurse has known for several years is wearing strong cologne. The nurse implements which intervention based on this observation?

Ensures that smoke detectors are present in the house

The nurse is caring for a client who is preparing to undergo a left mastectomy. As the nurse performs the physical assessment, the client informs the nurse that she is unable to accept blood products as treatment due to her religion. Which alternative treatment will the nurse address with the client?

Erythropoietin

Applying the Masters and Johnson description of sexual response, place the phases in the order in which they would occur from first to last

Excitement Plateau Orgasm Resolution

Applying the Masters and Johnson description of sexual response, place the phases in the order in which they would occur from first to last.

Excitement Plateau Orgasm Resolution

What is associated with the resolution phase of the male sexual response cycle?

Feelings of relaxation and fulfillment

A client is to receive a blood transfusion. Immediately after initiating the transfusion, the nurse suspects that the client is experiencing a hemolytic reaction based on which finding? Select all that apply.

Fever Facial flushing Low back pain Hematuria

A client is receiving a peripheral IV infusion and the electronic pump is alarming frequently due to occluded flow. What is the nurse's most appropriate action?

Flush the IV with 3 mL of normal saline

A nurse is obtaining an arterial blood specimen from a client to assess acid-base status. Which value is expected for a client with normal status?

HCO3: 25 mEq/L (25 mmol/L)

A 13-year-old female client comes in for a sports physical for school. During the exam, the client mentions she has a great boyfriend. Which question should the nurse prioritize with this client?

Have you received a human papillomavirus (HPV) vaccination?

A nurse is explaining premenstrual syndrome to a female client. The client demonstrates understands when stating what may occur in the premenstrual phase?

Headache

A man 68 years of age comes to the clinic complaining that he is having difficulty obtaining an erection. When reviewing the client's history, what might the nurse note that contributes to impotence?

History of hypertension

A client who is on hospice care and has no immediate family has been given less than 1 week to live. The nurse caring for the client recognizes that providing presence is most important, especially when a client is dying. What would be the best way for this nurse to provide presence to this client?

Hold the client's hand and sit by the bedside as often as possible.

The wife of a client who has been diagnosed with a terminal illness asks the nurse about the differences between palliative care and hospice care. Which information would the nurse most likely include in the response?

Hospice care is provided for clients who have 6 months or less to live; palliative care is provided at any time during illness.

A child 4 years of age has a mother who is employed and works from home. To accomplish her daily work, she allows the child to watch television for 6 to 8 hours a day. Based upon this information, what nursing diagnosis would be applicable to this family?

Impaired Parenting associated with failure to provide stimuli for growth

Many chronic medical problems adversely affect a person's ability to maintain normal fluid, electrolyte, and acid-base homeostasis. What describes complications related to liver disease?

Increased plasma levels of antidiuretic hormone lead to water excess.

The client is a young mother whose spouse died 3 months ago. The client is tearful and unkempt, eats a poor diet, and has lost 50 lb (22.6 kg) since the death of the spouse. The client states, "I can't do this anymore." The nursing diagnosis best supported by these data is:

Ineffective coping related to failure of previously used coping mechanisms

A nurse is assessing clients across the lifespan for fluid and electrolyte balance. Which age group would the nurse identify as having the greatest risk for these imbalances?

Infants

A nurse informs a woman that there is nothing more that can be done medically for her premature infant who is expected to die. The mother suppresses her grief and tells the nurse she is experiencing heart palpitations. What type of grief might the mother be experiencing?

Inhibited grief

A home hospice client who has Medicare is experiencing extreme pain at home and is refusing to receive inpatient care due to concerns over the cost of inpatient care. What teaching will the nurse include in the plan of care?

Inpatient pain management for hospice patients is covered by Medicare.

Which nursing interventions would be appropriate for a client diagnosed with deficient fluid volume? Select all that apply.

Intravenous therapy Electrolyte management Nutrition management

A client who is admitted to the ER with severe right-sided abdominal pain is diagnosed with appendicitis. The surgeon is called and proceeds to explain the procedure to the client and asks her to sign the consent. The client refuses and informs the doctor that her husband needs to be called to do this. Which of the following religions does this client likely practice?

Islam

While interviewing a hospitalized client, he states, "The holy days of Ramadan are coming soon. I am not to have any food or drink from sunrise to sunset during this time." Further assessment reveals that the client's request is associated with which religion?

Islam

The nurse is caring for a client who is preparing to undergo a left mastectomy. As the nurse performs the physical assessment, the client informs the nurse that she is unable to accept blood products as treatment due to her religion. The nurse interprets this as a belief of which religion?

Jehovah's Witnesses

The nurse is preparing a talk on health issues in the lesbian, gay, bisexual, transgender, queer or questioning (LGBTQ) population. Which statistic would the nurse include?

LGBTQ youth are more likely to attempt suicide.

A nursing student is studying spirituality and completing a report on The Church of Jesus Christ of Latter-day Saints. Which fact about this faith should the student include in the report?

Latter-day Saints are not allowed to use tobacco or alcohol.

A neonatal intensive care nurse is caring for an infant born prematurely. How will the nurse manage the infant's environment to best support his sensory needs?

Limit lighting, visual, and vestibular stimulation.

A client who is admitted for a debilitating disease is talking to the nurse. The client relates that family is the only thing that matters, stating that family helps fulfill all the spiritual needs by first fulfilling the most basic of all needs. What is this basic need?

Love

The nurse is advising an adolescent male about sexual myths that have him concerned. Which client education accurately describe these concerns? Select all that apply.

Masturbation or self-stimulation is a natural and healthy outlet for sexual urges. No male or female should feel pressured into sexual activity at any age. Nocturnal emissions are normal in men of all ages.

The school nurse is educating a group of 5th and 6th grade girls on menstruation. One girl asks if there is a name for having her first menstrual period. The nurse replies with which of the following terms?

Menarche

A young man has developed gastric esophageal reflux disease. He is treating it with antacids. Which acid-base imbalance is he at risk for developing?

Metabolic alkalosis

The nurse is reviewing the client's arterial blood gas results. The test reveals a pH of 7.52, a PaO2 level of 49 mm Hg (6.52 kPa) and an HCO3 level of 28 mEq/L (28 mmol/L), the nurse suspects the client is most likely experiencing which condition?

Metabolic alkalosis

A resident of a long-term care facility has moderate hearing loss. When communicating with this resident, what should the nurse do?

Minimize background noises and ensure that lighting is adequate to see the nurse's face.

A nurse is caring for a client experiencing new onset confusion. What should the nurse do to avoid injuries from falls?

Monitor the client frequently.

The nurse is caring for a client who has terminal lung cancer and is unconscious. What assessment would indicate to the nurse that the client's death is imminent?

Mottling of the lower limbs

The clinic nurse is explaining the action of sildenafil (Viagra) to a client. The nurse should assess his medication regimen to determine if he is taking medications that are contraindicated with Viagra. Which of the following medications is contraindicated with Viagra?

Nitrates

A nurse is providing care to a client who practices Buddhism. To ensure that the nurse meets the client's spiritual needs, the nurse reviews the major beliefs about this religion. The nurse demonstrates understanding of the information identifying which concept as the means to the cessation of suffering?

Noble Eightfold Path

As observed the nurse changing a peripheral venous access site dressing is demonstrating inappropriate technique by implementing which action?

Not wearing gloves when performing the intervention

The nurse is assessing a client for spirituality using the HOPE acronym. Which statement describes an element of this tool?

O = organized religion

An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations?

Offer small amounts of preferred beverage frequently.

A nurse is providing care to a client who is on fluid restriction. Which action by the nurse would be most appropriate?

Offer the client sugar-free candy to help combat thirst.

The nurse is preparing a 15-year-old adolescent for the first gynecological examination to evaluate heavy menstruation. Which intervention by the nurse will help the client feel less anxious during the gynecological examination?

Offer to remain with the client during the examination.

During the menstrual cycle, when does ovulation typically take place?

On day 14

Which nursing title is being recognized by the American Association of Nursing that aids and assists the clients with spiritual needs in the community setting?

Parish nursing

A nurse is providing end-of-life care to a terminally ill client. Which action should the nurse take to remove mucus and saliva from the client's mouth?

Perform suction in the client's mouth.

The nurse is administering intravenous (IV) therapy to a client. The nurse notices acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Which complication related to IV therapy should the nurse most suspect?

Phlebitis

The nursing diagnosis Spiritual Distress related to crisis of illness as evidenced by loss of meaning in life and overuse of pain medication is created for a client who attempted to take his life. Which intervention is appropriate for these problems?

Plan and coordinate a multidisciplinary team conference including the chaplain.

A female client informs the nurse that her husband is concerned about her sexual response. The client reports that during stimulation her husband has noticed her clitoris disappears, and he wonders if she is enjoying the experience despite her positive responses to his stimulation. The nurse explains that building excitement and the retraction of the clitoris are normal characteristics of which stage of the sexual response cycle?

Plateau phase

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte?

Potassium

A nurse is assessing a client after surgery and obtains the client's vital signs: pulse rate is 65 bpm, blood pressure is 122/76 mm Hg in the supine position. The nurse then obtains the client's vital signs on standing. Which finding would alert the nurse to the possibility of a an ECF volume deficit? Select all that apply.

Pulse rate 90 bpm Blood pressure 104/68 mm Hg

A client in a long-term care facility has recently begun to refuse to cooperate with the staff, is having difficulty agreeing with the treatment goals suggested by the nurse, and is showing more stress when the family goes home. What is the best response from the nurse?

Question the client concerning spiritual concerns

During hospitalization for a suicide attempt, the client informs the nurse that she does not want to return to work because her boss expects sexual favors each week before he gives her a paycheck. The client informs the nurse that she needs the job but is embarrassed that she performs these favors. The nurse informs the client that this is illegal behavior and is called what?

Quid pro quo harassment.

An older adult client is spiritual and has a deep faith. The client asks the nurse to say a prayer for the client. The nurse, who is not very comfortable praying out loud, wants to honor the client's request. What would be the best action by the nurse?

Read a printed interfaith prayer to the client.

The nurse is taking care of a client who is scheduled for a mastectomy. The client tells the nurse that the client is apprehensive about the operation and asks the nurse to read a passage from the Koran to help prepare the client for surgery. Which action by the nurse is the most appropriate?

Read the Koran passage to the client.

A nurse interviews a client and finds that, because of religious beliefs, the client's view on health care does not involve blood transfusions. How can the nurse best handle this client situation?

Record this information in the client's chart.

While studying religion and spirituality, the nursing student exhibits an understanding of the concepts when making which of the following statements?

Religion is a collection of spiritual beliefs and practices.

A nurse caring for a client of the Jewish faith knows the importance of asking about any food preferences when discussing diet. This is important for which reason?

Religious practices and beliefs can directly influence a client's self-care practices.

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action?

Remove the IV.

During the nurse's morning assessment of a client with a diagnosis of dementia, the client states that the year is 1949 and believing to be in a hotel. How should the nurse best respond to this client's disorientation?

Reorient the client to place and time.

The nurse is assisting a client with his meal selection for the next day. The client states, "I can't have meat tomorrow, it's a Holy Day." The nurse recognizes that the client is a member of which religious organization?

Roman Catholic

A school nurse is providing a class on sexually transmitted infections (STIs). Which statement is correct regarding STIs?

STIs are most prevalent among teenagers and young adults.

A nurse is assessing for the presence of edema in a client who is confined to bed and who often lies supine. The nurse would pay particular attention to which area?

Sacral area

When a nurse supports the client's spiritual needs, the nurse supports which level of the Maslow's hierarchy of needs?

Self-actualization needs

A cycling accident has resulted in a head injury to a client with resultant increased intracranial pressure. Consequently, the client has been placed in a private room with low light and care has been organized to minimize disturbances. What situation is the client most likely at risk for?

Sensory Deprivation

An intensive care unit (ICU) nurse does not notice the noise within the environment. However, a client's family member states, "How can you stand it here? The lights, sounds, and activity would drive me crazy and I could not take it." How might noise in the ICU affect the client's well-being?

Sensory overload can cause anxiety and irritability.

Allen is an 82-year-old retiree who recently relocated to senior apartments. The apartments are not affiliated with any religious beliefs. Allen was raised in the Roman Catholic church and has attended mass every Sunday since childhood. He has not attended mass for 3 weeks. What best describes Allen's situation?

Separation from spiritual ties

Which of the following statements best describes the relationship between biologic sex and gender identity?

Sex is chromosomally determined, while gender is a psychosocial construct.

Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium?

Sodium is regulated by the renin-angiotensin-aldosterone system.

A nurse is caring for Jeff, a 13-year-old boy who has suffered a concussion while playing hockey. The morning assessment finds him very drowsy but he responds normally to stimuli. What does the nurse document as his level of consciousness?

Somnolence

The nurse caring for a bedridden hospitalized client who states that this will be the first time that he has missed a Methodist church service in 50 years plans care based on which of the following NANDA-I diagnoses?

Spiritual Distress related to inability to attend church services evidenced by verbal states of guilt

A college foreign exchange student is living with a family in England and is confused about the daily Catholic prayers and rituals of the family. The student longs for the comfort of her fundamentalist Protestant practices and reports to the campus nurse for direction. The nurse recognizes the student is experiencing which type of spiritual distress?

Spiritual alienation

A client informs the nurse about being unsure of some of the health practices as a newly practicing Jehovah's Witness. What information can the nurse share with the client regarding cultural beliefs about blood products?

Spiritual care consultants can provide support to the client.

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?

Start an IV of normal saline as prescribed.

The nurse enters a client's room as the client and family are praying. Which is the most appropriate action of the nurse?

Step outside the door until the prayer is finished.

A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse?

Stop the transfusion and infuse normal saline using a new administration set.

During a blood transfusion of a client, the nurse observes the appearance of rash and flushing in the client, although the vital signs are stable. Which intervention should the nurse perform for this client first?

Stop the transfusion immediately

The nurse is caring for a client who sustained a traumatic brain injury in a skiing accident. The client is breathing independently, drowsy, but arousable with extreme or repeated stimuli. How will the nurse document the client's level of consciousness ?

Stupor

A nurse is developing a plan of care to meet a client's spiritual needs. When identifying appropriate interventions, which concept would the nurse need to integrate as the foundation for all the interventions?

Supportive presence

The nurse is conducting an assessment on a 42-year-old female client. The client admits to having unprotected sex with multiple individuals over the years. Based on the data collected during the assessment, which disorder should the nurse suspect this client has?

Syphilis

An older adult client who is very sick but very spiritual and has a deep faith asks the nurse to say a prayer for her. The nurse, who is not very comfortable praying out loud, wants to honor the client's request. What would be the best action by the nurse?

Take the lead from the client by asking, "How would you like us to pray?"

A client returning from the operating room is unconscious. What guidelines should the nurse consider when communicating with this client?

Talk to the client in a normal tone of voice.

A 19-year-old client scheduled for a vaginal exam is visibly upset and cancels the appointment when learning the clinic provider is a man. Which factor should the nurse prioritize when assisting this client?

Taught to avoid exposing herself to strangers

The nurse is counseling an elderly client. Because of the client's age, the nurse recognizes that she is at risk for macular degeneration. Which of the following is a priority nursing intervention?

Teach the client signals of serious eye problems, such as visual disturbances.

The nurse is caring for a client who asks that the special undergarments not be removed for an upcoming procedure. The nurse is aware that these undergarments are related to the client's religion. This religion is:

The Church of Jesus Christ of Latter-day Saints.

Traditionally, the male sexual response is thought to be broken up into three phases. Which occurrence is part of the plateau phase?

The circumference of the penis thickens at the coronal ridge and a few drops of fluid appear at the urethral meatus.

A nurse at the health care facility cares for several clients. Some of the clients may require end-of-life care. Which case may require the service of a coroner?

The client did not have any recent medical consultation.

The nurse is creating a plan of care for a client experiencing spiritual distress. What is the priority outcome for this care plan?

The client expresses meaning and purpose in life

The nurse is preparing a packed red blood cell transfusion for a client. The nurse checks the client's blood type in the electronic medical record (EMR) and notes that it is blood type B. What does this mean?

The client has anti-A antibodies.

A client in a long-term care facility has signed a form stating that he does not want to be resuscitated. He develops an upper respiratory infection that progresses to pneumonia. His health rapidly deteriorates, and he is no longer competent. The client's family states that they want everything possible done for the client. What should happen in this case?

The client should be treated with antibiotics for pneumonia.

The home health nurse is visiting a client who has been living alone for the past 5 years following the death of the spouse. Which behavior suggests the client may be experiencing abnormal grief?

The client talks as if the loss just happened.

A new nurse observes a priest visiting the clients every Saturday afternoon and praying with them. This activity supports which of the nursing outcomes?

The client uses a type of spiritual experience that provides comfort.

The nurse is creating a care plan for the legally blind client who is confused and easily agitated. Which priority outcome is appropriate for this client?

The client will remain safe.

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?

The client's breathing becomes noisy.

Which does not coincide with Kübler-Ross's stages related to a dying client?

The dying client usually exhibits anger first.

A client is in the late stages of lung cancer with bone metastases. Since receiving the terminal diagnosis, the client has often made mentioned an estranged child and being a "miserable parent." Which conversation will the nurse have with the client to attend to unfinished business?

The need for forgiveness

The nurse takes into consideration developmental stage when assessing sexuality. Which is an example of a developmentally appropriate intervention?

The nurse teaches parents of a 4-year-old child that they may cause anxiety in the child by intolerance of inconsistency of sex-role behavior.

A patient calls the clinic and tells the nurse they have a foamy, greenish, and itchy vaginal discharge. The patient asks the nurse what the significance of this discharge is. What is the best response by the nurse?

The patient may have trichomoniasis.

The nurse is describing the role of antidiuretic hormone in the regulation of body fluids. What phenomenon takes place when antidiuretic hormone is present?

The renal system retains more water.

The nurse is assessing a client's intravenous line and notes small air bubbles within the tubing. What is the priority nursing action?

Tighten the roller clamp to stop the infusion.

What is the priority goal for the activity in which the nurse is engaging, related to the administration of a prescribed IV solution?

To assure the IV solution is appropriate for this administration

A client visits a community clinic reporting a foul-smelling vaginal discharge that is thin, foamy, and green in color; itching of vulva and vagina; and burning on urination. Which STI would the nurse suspect?

Trichomonas vaginalis

Which sexually transmitted infection has the following characteristics: thin, foamy, greenish vaginal discharge that causes itching of the vulva and vagina?

Trichomoniasis

The husband of a client who has died cannot express his feelings of loss and at times denies them. His bereavement has extended over a lengthy period. What type of grief is the husband experiencing?

Unresolved grief

A male client comes to the clinic because he thinks that he has syphilis. Which test would the nurse expect the client to have done?

VDRL

The nurse is assessing the sexual health of a female client age 20 years. During the interview, the client says, "I feel that my vaginal opening constricts whenever I am about to have intercourse. I seem to have no control over it." What would the nurse use when documenting the client's report?

Vaginismus

Which way can the nurse decrease the sensory deprivation that the client in isolation experiences?

Visit the client often to develop trust.

Which statement most accurately describes the process of osmosis?

Water moves from an area of lower solute concentration to an area of higher solute concentration.

Mr. V. is recovering from pneumonia. The nurse understands that a well-balanced diet will help him to recover. However, Mr. V. informs the nurse that it is Ramadan and he must fast from sunrise to sunset. What is the nurse's most appropriate nursing action?

Work with the nutrition staff to provide nutritious meals at off hours.

A client recently diagnosed with cancer informs the nurse that they value faith and finds comfort in their faith. The nurse is aware that faith is best defined as:

a belief in something for which there is no proof or material evidence.

The nurse is caring for several clients in the home care setting. Which client, when found deceased, will the nurse report as a case for the medical examiner?

a client found with an empty bottle for a newly-prescribed opioid by the bedside

Which client would be a candidate for total parenteral nutrition?

a client with colitis and bloody diarrhea

The nurse should explain to the client's family member that a comfort-measures-only order is being implemented to obtain which expected outcome?

a comfortable, dignified death for the client

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first?

a newly admitted 88-year-old with a 2-day history of vomiting and loose stools

An infant is brought to the emergency room with dehydration due to vomiting. After several failed attempts to start an IV, the nurse observes a scalp vein. When accessing the scalp vein, the nurse should use:

a winged infusion needle.

The cardiac monitor technician is installing new monitors. The intensive care unit (ICU) nurse asks that the monitors have different sound levels for the more lethal alarms as the repeated stimulus of a continuing noise often goes unnoticed. The ICU nurse explains that this phenomenon is

adaptation.

The cardiac monitor technician is installing new monitors. The intensive care unit (ICU) nurse asks that the monitors have different sound levels for the more lethal alarms as the repeated stimulus of a continuing noise often goes unnoticed. The ICU nurse explains that this phenomenon is known as:

adaptation.

A client has recently lost a parent. The client spent about 6 months deeply mourning the loss and is just now able to function at the pre-loss level. During this process, a strong social support network was able to assist the client. What developmental stage of life does the nurse identify the client is in?

adult

A hospice nurse has developed a care plan for a client with liver cancer. The care plan focuses on providing palliative care for this client. The goal of palliative care is best described as providing clients with life-threatening illnesses a dignified quality of life through which means?

aggressive management of symptoms

The nurse is caring for a client who states, "No one can understand God." The nurse would document the client's spiritual belief as:

agnostic.

To meet the learning needs of the older adult, the nurse incorporates which considerations in planning to educate a 73-year-old client with diabetes about insulin administration?

allowing more time for the processing of the information

Which client is at greatest risk of sensory overload?

an 88-year-old on a ventilator in an intensive care unit

Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid?

an infant age 4 months

The spouse of a recently deceased client states, "I just can't believe he left me. He swore he would never leave me and I feel betrayed!" Using Kübler-Ross stages of grief, what stage does the nurse identify the client is experiencing?

anger

The nurse is meeting an older adult client for the first time in their hospital room. Which of the following interventions should be a priority at this time?

asking if the client uses prescription glasses.

A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that they had a banana, yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern?

banana

A client with a terminal illness is overheard by the nurse saying, "If I promise never to smoke another cigarette in my life, please let me recover from this lung cancer." How will the nurse document this stage of grief according to the Kübler-Ross model?

bargaining

What is Kübler-Ross's third stage of grief?

bargaining

A widow develops cancer within 6 months of her husband's death. This may be a result of:

bereavement.

A client has been admitted with fluid volume deficit. Which assessment data would the nurse anticipate? Select all that apply.

blood pressure 100/48 mmHg poor skin turgor heart rate 128/bpm

The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland?

calcium and phosphorus

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?

cardiac irregularities

A client has a diagnosis of bladder cancer with metastasis. The client asks the nurse about the characteristics of hospice care. The nurse should explain that:

care is premised on the fact that dying is a normal process.

Which is a common anion?

chloride

During a routine physical exam, a male client informs the nurse that he frequently participates in anal intercourse with his new girlfriend. The nurse discusses this practice with the client by informing him that:

condoms are recommended for anal intercourse.

The nurse should inform a young female client that the barrier method providing the best protection against sexually transmitted infections (STIs) is:

condoms.

Upon admission, the nurse should give priority to addressing which need of a client who is displaying symptoms of dysfunctional grief?

coping strategies

A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor?

decreased blood volume and intracellular dehydration

The nurse is caring for a hospitalized 90-year-old client. What will the nurse include in the care plan?

decreasing environmental noise

A nurse is assessing a client's state of awareness and finds the client to be disoriented and restless. The client is also agitated and alternates from confusion to excessive drowsiness to extreme excitability. The nurse would document this as:

delirium.

A nursing instructor is speaking to a group of nursing students about proper care of the ears to promote hearing, as well as techniques to follow when working with clients with hearing impairments. An appropriate nursing intervention discussed by the instructor includes:

demonstrating or pantomiming ideas to clients with hearing impairments.

A client is informed about the results of a biopsy, which indicate a malignant tumor that has spread. The client states, "Well once you remove the tumor, I will be just fine." What stage of the grief process does the nurse identify the client is experiencing?

denial

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?

distended neck veins

The parents of three children ages 4, 7, and 11 years are interested in fostering spiritual development in their children. The nurse informs the parents that the development of a child's spirituality is best accomplished by:

educating through parental behaviors.

After surgery, a client is on IV therapy for the next 4 days. How often should the nurse change the IV tubing for this client?

every 72 hours

When a man cannot achieve an erection, the phase of the sexual response in which the man is experiencing difficulty is:

excitement phase.

The client states "I have lifted my cancer to God and am accepting of God's plan for me." This is an example of an adaptive expression of spiritual needs labeled:

faith

Within 15 minutes after the start of a blood transfusion, the client complains of chills and headache. During frequent vital signs, the nurse begins to see an elevation in the temperature. What condition is the client experiencing?

febrile reaction

The process of filtration begins at the:

glomerulus

The nurse is conducting health education with a group of older adults in the clinic. Which activity should the nurse include in the education that can prevent sensory loss in the older adult population?

good management of illness such as hypertension

A client diagnosed with liver failure in hospice care died 10 hours ago. The client's spouse is having difficulty leaving the room and is crying uncontrollably. What situation does the nurse identify is happening with this client's spouse?

grief reaction

After cataract surgery the client's home environment may increase the risk for falls. Which nursing intervention should facilitate safety of the environment?

having a caregiver in the home for the first few days after surgery

After cataract surgery the client's home environment may increase the risk for falls. Which nursing intervention should facilitate safety of the environment?.

having a caregiver in the home for the first few days after surgery

The nurse is providing education about sexuality to a group of college freshmen. Which terms(s) describe a client's sexual orientation? Select all that apply.

heterosexual (straight) gay lesbian

While interviewing a client, a nurse is told that the client practices Catholicism. This client is identifying:

his faith.

During the orgasmic phase of the sexual response, the woman may experience:

hypertension.

The nurse is caring for a client who was in a motor vehicle accident and has severe cerebral edema. Which fluid does the nurse anticipate infusing?

hypertonic

The nurse is caring for a client, who was admitted after falling from a ladder. The client has a brain injury which is causing the pressure inside the skull to increase that may result in a lack of circulation and possible death to brain cells. Considering this information, which intravenous solution would be most appropriate?

hypertonic

A nurse is reviewing the client's serum electrolyte levels which are as follows: Sodium: 138 mEq/L (138 mmol/L) Potassium: 3.2 mEq/L (3.2 mmol/L) Calcium: 10.0 mg/dL (2.5 mmol/L) Magnesium: 2.0 mEq/L (1.0 mmol/L) Chloride: 100 mEq/L (100 mmol/L) Phosphate: 4.5 mg/dL (2.6 mEq/L) Based on these levels, the nurse would identify which imbalance?

hypokalemia

A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of:

hypokalemia.

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

hypovolemia

The nurse is instructing a client about the performance of Kegel exercises. What statement made by the client about the purpose of Kegel exercises indicates to the nurse that further education is required?

increased abdominal strength.

A nurse is preparing an education plan for a client with heart failure who is experiencing edema. As part of the plan, the nurse wants to describe the underlying mechanism for why the edema develops. Which mechanism will nurse likely address?

increased hydrostatic pressure

When admitting a wheelchair-bound client with paraplegia to the hospital, the nurse assesses the client for injuries. What injuries should the nurse assess the client for that may occur?

injuries that occur from sensory alteration

When the mother of a 2-year-old tells the pediatric nurse that the child masturbates, the nurse informs the mother that the child:

is exhibiting normal behavior.

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

isotonic

Which nursing interventions support the older adult client's sensory needs while admitted in the hospital?

keeping the room well lighted

A nurse is teaching a sex education class to a group of adolescent girls. They ask the nurse about the sexual response cycle in females. Which physiologic response does the nurse tell them is only seen in girls/women?

loss of muscular control during orgasm causing twitching of the arms and legs

The experience of parting with an object, person, belief, or relationship that one values is defined as:

loss.

When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L (140 mmol/L); potassium, 4.1 mEq/L (4.1 mmol/L); calcium 7.9 mg/dL (1.975 mmol/L), and magnesium 1.9 mg/dL (0.781 mmol/L); the nurse should notify the physician of the client's:

low calcium.

A group of nursing students is reviewing information about body fluid and locations. The students demonstrate understanding of the material when they identify which of the following as a function of intracellular fluid?

maintenance of cell size

Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL (2.05 mmol/L). For what assessment findings will the nurse be looking?

muscle cramping and tetany

During the plateau phase of the sexual response, the man may experience:

nipple erection.

In the Parkes model, a person uses denial as a psychological defense in the stage of:

numbness.

A nurse is providing care to a client with an extracellular fluid (ECF) volume deficit. The nurse suspects that the deficit involves a decrease in vascular volume based on which finding? Select all that apply.

orthostatic hypotension decreased urine output slow-filling peripheral veins

A female client who underwent a mammogram earlier in the day is asked to have a breast ultrasound, and then informed that she demonstrates signs of breast malignancy. The nurse knows that the client is at risk for experiencing sensory:

overload.

An appropriate goal for the client with a nursing diagnosis of Spiritual Distress related to intense pain and suffering as verbalized by the client would be that the client will:

participate in supportive spiritual practices.

The nurse is caring for a client diagnosed with vaginismus. When reviewing the client's history, what would the nurse would expect to find?

past history of a rape

When a person selects, organizes, and interprets sensory stimuli, the process is termed:

perception.

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of:

phlebitis.

A nurse is providing postmortem care. Which of the following nursing actions is a legal responsibility?

placing ID tags on the shroud and ankle

A client sustained severe trauma in a motor vehicle accident and has had 26 units of packed red blood cells infused since admission 2 days previously. What does the nurse predict will be prescribed to replace the clotting factors lost with the infusion of large amounts of packed red blood cells?

plasma

A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client?

platelets

When a 19-year-old male client tells the nurse that he has never been able to achieve an erection, the nurse recognizes that the client is experiencing:

primary impotence.

Which assessment question is most likely to yield When a 19-year-old male client tells the nurse that he has never been able to achieve an erection, the nurse recognizes that the client is experiencing:

primary impotence.

The Surgeon General's Call To Action To Promote Sexual Health and Responsible Sexual Behavior was released in 2001. The goal of this document is to:

promote general health and wellness.

The plan of care for a client exhibiting signs of sensory deprivation includes incorporating tactile stimulation. Which nursing intervention will provide tactile stimulation?

providing a backrub with morning and evening care

What is the most important goal of care for the dying client who is receiving comfort care?

providing a comfortable, dignified death

The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client?

renal failure

A decrease in arterial blood pressure will result in the release of:

renin.

The nurse is talking with the son of a client with end-stage renal failure and late-stage dementia. The client can no longer live at home, and the son states, "I live 500 miles away. I don't know what to do." Which type of living arrangement will the nurse teach the son about?

residential care

Which care environment would the nurse suggest to a client with no family nearby who is diagnosed with end-stage lung disease?

residential care

A hospital client has been awakened at night by the alarm on his roommate's intravenous pump. This client was aroused by brain action in his:

reticular activating system (RAS).

A client who has awakened from a coma after a car accident and states, I knew about a news story reported during the time I was in the coma." What does the nurse identify is occurring with the client?

reticular activating system's stimulation.

The nurse should instruct an Islamic female client who is reluctant to undergo pelvic examination from an assigned male health care provider to:

seek a female health care provider to perform the examination.

A nurse is assisting a terminally ill female client with bathing. The client tells the nurse that she has great respect and faith in a particular spiritual leader. The nurse interprets this information as fulfilling which need for the client?

sense of security for present and future

A client who is blind is said to be experiencing:

sensory deficit.

A client who hallucinates simply to maintain an optimal level of arousal is experiencing:

sensory deprivation.

A client has just been told that he has lung cancer. The physician then describes several potential courses of treatment to the client. When the physician leaves the room, the client asks the nurse, "What did he just say?" The nurse understands that the client is experiencing:

sensory overload.

A client has expressed great relief at the improvement in their hearing after irrigation of the ear canal yielded a large amount of impacted cerumen. This client was experiencing a sensory alteration related to:

sensory reception.

Which stage of grieving is exhibited by the husband of a victim of sudden death who refuses to accept that she is dead?

shock

The nurse is preparing to provide education to a group of high school students on sexually transmitted infection (STI) prevention. The nurse knows that this age group often uses oral-genital stimulation as a way to prevent pregnancy. Which concept should the nurse make sure to convey to the group?

skin-to-skin contact can spread herpes and genital warts

The children of a male client with late-stage Alzheimer disease have informed the nurse on the unit that their father possesses a living will. The nurse should recognize that this document is most likely to:

specify the treatment measures that the client wants and does not want.

A new client is on the hospital unit. He was recently diagnosed with metastatic pancreatic cancer and was told that any treatment would be palliative. He tells a nurse that there is no God that he knows of who would subject someone to this. The client's statement is most reflective of:

spiritual crisis.

While assessing a client's neurological status, the nurse asks the client to close the eyes and identify the object placed into the hand. The nurse explains that this test if the client is able to identity the solidity, size, shape, and texture of the object. The nurse documents this ability as:

stereognosis.

When preparing for a spiritual counselor to visit a hospitalized client, the nurse should:

take measures to ensure privacy during the counselor's visit.

A terminally ill client tells the nurse that he does not belong to an organized religion. It is safe for the nurse to assume:

the client may still be deeply spiritual.

A client that is post-menopausal reports painful intercourse for the last two months. When performing an assessment of the client, what data should the nurse obtain?

the use of antihistamines, tranquilizers, or alcohol

When the client tells the nurse that she believes God's reality is personal, and that God is the creator of all beings, the nurse determines the client is expressing:

theism

The nurse is giving palliative care to a client with a diagnosis of COPD. What is the goal of palliative care?

to improve the client's and family's quality of life

Palliative care is a structured system for care delivery. What is its aim?

to prevent and relieve suffering

A sensory deficit that may arise from the client's eyes being bandaged after eye surgery can result in:

total disorientation.

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as:

total parenteral nutrition.

A female client presents with a report of pain and burning in the area of the vulva during intercourse. How will the nurse document the clients report of symptoms?

vulvodynia