3234 Final Exam
A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 48 mmHg and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate which of the following acid base balances?
Respiratory acidosis
A nurse is teaching a home care client and the family about using prescribed oxygen. What is a critical factor that must be included in teaching?
the safety measures necessary to prevent a fire
A nurse is assessing the stools of a breast-fed baby. What is the appearance of normal stools for this baby?
yellow, loose, odorless
A nurse is preparing to administer fluconazole 400 mg by intermittent IV bolus daily. Available is fluconazole in 0.9% sodium chloride 200 mL to infuse over 2 hr. The nurse should set the IV pump to deliver how many mL/hr?
100 mL/hr
A client with an upper respiratory infection (common cold) tells the nurse, "I am so angry because the nurse practitioner would not give me any antibiotics." What would be the most appropriate response by the nurse?
"Antibiotics have no effect on viruses.
A client is experiencing withdrawal from alcohol and admitted to the behavioral health unit. The client begins to have muscle weakness, tremors, hyperactive deep tendon reflexes, and a change in mental status. What should the nurse prepare to replace in this client?
Magnesium
A dying client and family have requested that no attempts be made to resuscitate the client in the event of death. A doctor has written a DNR order. What is the nurse's responsibility if the client dies?
Make no attempt to resuscitate the client.
A nurse has developed a plan of care with nursing interventions designed to meet specific client outcomes. The outcomes are not met by the time specified in the plan. What should the nurse do now in terms of evaluation?
Make recommendations for revising the plan of care
An assistive personnel reports to the nurse that a client who is 3 days postoperative following an abdominal hysterectomy has a dressing that is saturated with blood. Which of the following tasks should the nurse delegate to the AP?
Obtain vital signs
The nurse is implementing comfort measures to promote sleep for a client. Which intervention is the best choice for the client?
Offer client a small carbohydrate and protein snack before bedtime.
A nurse is caring for a client who has a new prescription for a low-sodium diet. The client's family has requested to bring in some of the client's favorite foods. Which of the following food items should the nurse tell the family members to omit?
Pickled vegetables
The client is in the intensive care unit following a stroke. The nurse is intervening in the plan of care to promote relaxation for the client and to prevent sensory overload. What independent nursing intervention would the nurse choose to do?
Play music the client choses
A nurse is formulating a nursing diagnosis for a client who is reliving a brutal mugging that took place several months ago. The client reports having flashbacks of the experience and fear of leaving the house alone. Which nursing diagnosis for this client is a NANDA-I-approved problem statement and correctly written?
Post-trauma Syndrome related to being attacked
A nurse is providing teaching for a client who is on diuretic therapy and has a new prescription for potassium chloride (KCL) 20 mEq extended release PO daily. Which of the following instructions should the nurse provide about the new prescription?
Take the extended release tablets whole
While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first?
Wash the site of injury with soap and water
The nurse would recognize which client as being particularly susceptible to impaired wound healing?
an obese woman with a history of type 1 diabetes
After reviewing the client's chart, the nurse notes that the client has been ordered a clear liquid diet. Which meal tray would the client be allowed to eat?
bouillon, apple juice, and gelatin
A nurse is caring for a client with pneumonia. The client's oxygen saturation is below normal. What abnormal respiratory process does this demonstrate?
changes in the alveolar-capillary membrane and diffusion
A client has an abrupt onset of a cluster of global changes in attention, cognition, and level of consciousness (LOC). What would be the most appropriate nursing diagnosis?
Acute confusion
Which is the purpose of a focused assessment?
Adds depth to existing information
A client is having difficulty having a bowel movement on the bedpan. What is the physiologic reason for this problem?
The position does not facilitate downward pressure.
The health care provider writes a prescription for ampicillin 1 gram every 6 hours for a client. What would cause the nurse to question this medication prescription?
The route is missing
The nurse is caring for a client with terminal illness. Which should the nurse teach the family about physiological signs of imminent death?
There will be changes in vital signs, skin color, and responsiveness.
A nurse observes that a client who underwent knee surgery 2 weeks ago needs progressively larger doses of analgesics to get relief from pain. The nurse interprets this as:
Tolerance
A nurse is discussing neonatal care with a new mother. Which statement by the nurse best describes the value of breastfeeding?
"Breastfeeding provides the neonate with immunity against some bacteria and viruses."
A nurse is conducting an interview with a client to collect a medication history. Which question would be used to ensure safe medication administration?
"Do you have any allergies to medications?"
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?"
While caring for a female client near end of life, a nursing student talks to her. Another nursing student asks why she is talking to someone who is dying. Which response would be accurate?
"I believe the client can hear me as long as she is alive."
The nurse has completed teaching regarding pediculosis. Which client statement requires further nursing teaching?
"I will use a conditioner so that the lice eggs will slide off my hair.
A nurse is providing teaching to a client about measures to prevent urinary tract infections. Which of the following client statements indicates a need for further teaching?
"I will need to wipe my perineal area from back to front after urination"
A female client has recently had surgery for cervical cancer and asks the nurse about other ways she can have sex with her husband. Which of the following statements by the nurse is most accurate?
"Stimulation of the genitals by the mouth and tongue may be used to reach orgasm."
A client who had a recent amputation below the knee tells the nurse about feeling as though the toes are cramping in the missing leg. Which statement will the nurse use to educate the client?
"That is called phantom pain and it is not unusual."
A nurse is preparing an in-service program about preventing medication errors when transcribing a prescription. The nurse is using a dosage example of two tenths of a milligram. Which of the following examples should the nurse use to show appropriate transcription of this dosage?
0.2 mg
A client with a complex cardiac history has been prescribed digoxin 0.0625 mg PO. The drug is available as 125 mcg tablets. How many of the tablets will the nurse administer?
0.5
A nurse is converting the dosage of a medication to a different unit in the metric system. The medication label specifies the drug as being 0.5 g per tablet. The order is for 500 mg. How many tablets will the nurse give?
1
A nurse is caring for a client who has a deep vein thrombosis and is prescribed heparin by continuous IV infusion at 1,200 units/hr. Available is heparin 25,000 units in 500 mL D5W. The nurse should set the IV pump to deliver how many mL/hr?
24 mL/hr
A nurse performing a nutritional assessment determines that the BMI of a 5-foot, 11-inch (1.8 m) male client who weighs 81 kg is which of the following?
25
A nurse is calculating the intake of a client during the past 9 hr. The client's intake includes lactated ringers IV at 150 ml/hr, cefazolin 2 g IV intermittent bolus in 100 mL of 0.9% sodium chloride, two units of packed RBCs of 275 mL and 250 mL; two IV bolus infusions of 250 mL of 0.9% sodium chloride, ranitidine 50 mg IV intermittent bolus in 50 mL of dextrose 5% in water. How many mL of intake should the nurse record?
2525
A nurse is preparing to instill 840 mL of enteral nutrition via a client's gastrostomy tube over 24 hr using an infusion pump. The nurse should set the infusion pump to deliver how many mL/hr?
35 mL/hr
A nurse is planning care for a client who is to receive packed RBCs. The nurse should plan for the total infusion time to not exceed which of the following?
4 hr
A nurse is preparing to administer amoxicillin 30 mg/kg/day divided equally every 12 hr to a toddler who weighs 33 lb. Available is amoxicillin 200 mg/5 ml suspension. How many mL should the nurse administer?
5.6 mL
A client has not voided for 8 hours after surgery. Which finding indicates the client has a distended bladder?
A bulge between the symphysis pubis and the umbilicus
Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)?
A client has asked a nurse if he can read the documentation that his physician wrote in his char
Which client would be the best candidate to receive epidural analgesia for pain management?
A client recovering from recent hip replacement surgery
A nurse is admitting a client who has active tuberculosis to a room on a medical - surgical unit. Which of the following room assignments should the nurse make for the client?
A room with air exhaust directly to the outdoor environment
The nurse mistakenly documented one client's assessment data on another client's health care record. What action should the nurse take?
Draw a single line through the error, initial it, and write the correct entry.
A nurse caring for a female client notes a number of laceration wounds around the cervix of the uterus due to birth. How could the nurse describe the laceration wound in the client's medical record?
A separation of skin and tissue in which the edges are torn and irregular
A client tells the nurse that he takes laxatives every day but is still constipated. The nurse's response is based on which reasoning?
Habitual laxative use is the most common cause of chronic constipation.
Which is the most frequent reason for revocation or suspension of a nurse's license?
Alcohol or drug use
A client diagnosed with anemia is receiving a blood transfusion. The client develops urticaria accompanied by wheezing and dyspnea not long after the transfusion starts. The nurse interprets this as indicative of:
Allergic reaction
When the client demonstrates a rash 30 minutes after taking a dose of penicillin, the nurse recognizes that the client is likely demonstrating which type of drug reaction?
Allergy
What does pulse oximetry measure?
Arterial oxygen saturation
Which statement about glove use and hand hygiene is true?
Artificial fingernails should not be worn by staff involved in direct client care
A nurse drafts an SBAR communication before contacting the primary care provider of a client whose condition has worsened suddenly. How should the nurse best conclude this communication?
Ask the care provider to come and assess the client
A nurse is educating a client on how to administer insulin, with the expected outcome that the client will be able to self-administer the insulin injection. How would the nurse evaluate this outcome?
Ask the client to demonstrate self-injection of insulin
A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first?
Assess the client
A nurse on a medical-surgical unit is preparing to contact a provider about a client's condition. The client is 6 hr postoperative from a total hysterectomy. The nurse notes the client's postoperative oxygen saturation is 94% and her apical heart rate is 110. The nurse should include information about the client's oxygen saturation level and heart rate in which component of the SBAR report?
Assessment
A client who has to undergo a parathyroidectomy is worried about possibly having to wear a scarf around the neck after surgery. What nursing diagnosis should the nurse document in the care plan?
Disturbed Body Image related to the incision scar
A nurse is teaching a client who has gastroesophageal reflux disease about managing his illness. Which of the following recommendations should the nurse include in the teaching?
Avoid eating within 3 hr of bedtime
How may a nurse demonstrate cultural competence when responding to clients in pain?
Avoid stereotypical responses to pain in clients
A nurse is taking care of a client who needs a bed bath. Which action can the nurse delegate to an unlicensed assistive personnel (UAP)?
Back massage
The client is a middle-aged female who has been told she has cancer of the plasma. She states to the health care team, "Just keep me alive until I can see my daughter graduate from high school." What stage of dying is this client exhibiting?
Bargaining
The nursing is caring for several clients. Which intervention can the nurse direct the unlicensed assistive personnel (UAP) to perform?
Bathe a client with stable angina who has a continuous IV infusing.
A nurse in an emergency department is caring for an infant who has a 2 day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss?
Body weight
A nurse is caring for a client who has HIV. Which of the followinng laboratory values is the nurse's priority?
CD4-T-cell count 180 cells/mm3
A nurse in a provider's office is reviewing the laboratory results of a client who takes furosemide for hypertension. The nurse notes that the client's potassium level is 3.3 mEq/L. The nurse should monitor the client for which of the following complications?
Cardiac dysrhythmias
Upon evaluation of a client's medical history, the nurse recognizes that which condition may lead to an inadequate supply of oxygen to the tissues of the body?
Chronic anemia
Which entry would be an example of appropriate documentation?
Client stated, "I am so down today, and I just don't have any energy."
A nurse is inserting an indwelling urethral catheter. Which action does the nurse take to prepare the client to cooperate during the insertion of a catheter?
Close the door and curtain and explain the procedure to the client
A nurse is giving change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brainn injury. Which of the following information should the nurse include in the background segment of SBAR?
Code status
A nurse instructs a client to tell the nurse about the side effects of a medication. What learning domain is the nurse evaluating?
Cognitive
A nurse on a quality control committee is evaluating the results of recently implemented measures designed to reduce client medication errors. Which of the following methods should the nurse use to evaluate the success of the changes?
Compare the number of medication errors before and after the action was implemented
A nurse is caring for an older adult client who has a urinary tract infection. Which of the following manifestations should the nurse identify as a finding specifically associated with this client?
Confusion
The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia?
Confusion
The nurse cares for a client with a chronic neurologic condition that decreases the peristalsis. What nursing diagnosis is the most likely risk for this client?
Constipation
Which is an example of a nursing diagnosis?
Constipation
While assessing a postoperative client, the nurse notes the client's vital signs are within normal limits, the white blood cell count is 12,000/µL (12 × 109/L), and the client's abdominal wound has a 0.5-in (1.25-cm) gap at the lower end with yellow-green discharge. The nurse would prioritize which intervention?
Contact the health care provider.
While reviewing an adult client's chart, a nurse notes average daily intake of fluids as 2,000 mL/day. What will the nurse do based on this information?
Continue with care; this is a normal fluid intake
A client is prescribed escitalopram, diuretics, and pseudoephedrine. The client states, "I'm tired all the time." What does the nurse understand may be happening to this client?
Decrease in R.E.M. sleep due to prescribed medications
A nurse is caring for older adult clients in an assisted-living facility. Which effect of aging should the nurse consider when performing a urinary assessment?
Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infection
The nurse provides care for the client with chronic obstructive pulmonary disease experiencing hypoxia. Which assessment prompts the nurse to immediately report findings to the health care provider?
Decreased levels of consciousness
A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client?
Dehiscence of the wound
A nurse in the emergency department is caring for a client who collapsed after playing football on a hot day. After reviewing the admission laboratory findings. The nurse recognizes that these findings are consistent with which of the following conditions. Sodium 152 mEq/L, Potassium 3.6 mEq/L, Chloride 105 mEq/L, Glucose 102 mg/dL, BUN 18 mg/dL, Creatinine 0.7 mg/dL
Dehydration
A nurse is reviewing the medical record of a client who has a urinary tract infection. Which of the following findings should the nurse recognize as a risk factor?
Diabetes mellitus
While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first?
Discontinue the existing IV line
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 nurse is caring for a client who is being treated for bladder infection. The client reports to the nurse that he has been having difficulty voiding and feels uncomfortable. How should the nurse document the client's condition?
Dysuria
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.
A nurse is assessing an IV infusion site on an infant's left hand. Which of the following findings should the nurse identify as an indication of an infiltration?
Edema in the palm of the hand
What is the most critical element to document regarding client education?
Evidence that learning has occurred
Upon assessment, the nurse determines the client has a body mass index (BMI) of 45. This finding indicates the client is:
Extremely obese
A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?
Flush the NG feeding tube with 30 mL of water immediately following medication administration
A client has been prescribed a clear liquid diet. Which food or fluids should the nurse serve the client?
Gelatin desert, carbonated beverages, and apple juice
A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
Generalized urticaria
A client asks the nurse whether the generic acetaminophen is as effective as the brand name product. Which is the nurse's best response?
Generic medication performs the same as the corresponding brand-name product.
A nurse is obtaining an arterial blood specimen from a client to assess acid-base status. Which value is expected?
HCO3: 25 mEq/L (25 mmol/L)
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 nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?
Hypotension
The nurse is educating a group of clients in the community about safe sex practices. When is the best time to evaluate teaching effectiveness?
Immediately after the education session
Which strategy might a nurse use to increase compliance with education?
Include the client and family as partners
Which nursing diagnosis has priority?
Ineffective Airway Clearance related to retention of secretions
A nurse is formulating a nursing diagnosis for a client with a respiratory disease. Which nursing diagnosis would be correct?
Ineffective Airway Clearance related to thick mucus
A health care provider approaches the nurse caring for the client in room 25 and states, "The client is a friend of mine. What treatment is being given?" Which response by the nurse is most appropriate?
Inform the health care provider that client permission is needed to release any information.
What is the route of administration for TPN?
Intravenous
A client reports postoperative pain of 9 on a scale of 10 and asks the nurse whether a shot or a pill will provide the fastest pain relief. Which is the best response from the nurse?
Intravenous medication provides the fastest pain relief until you can take pills by mouth.
Two nurses are discussing a client's condition in an elevator full of visitors. With what tort might the nurses be charged?
Invasion of privacy
While riding in the elevator, a nurse discusses the HIV-positive status of a client with other colleagues. The nurse's action reflects:
Invasion of privacy
A nurse manager notes an increase in the frequency of client falls during the last month. To promote a positive working environment, how would the nurse manager most effectively deal with this problem?
Investigate the circumstances that contributed to client falls.
A client is hypotensive secondary to hypovolemia resulting from dehydration. Based on the nurse's knowledge about intravenous solutions, the nurse would expect the physician to prescribe which type of solution?
Isotonic
The nurse enters a client's room to find the client diaphoretic (sweat-covered) and shivering and infers that the client has a fever. How should the nurse best follow up this cue and inference?
Measure the client's oral temperature
A nurse uses the SBAR method in a hand-off report to communicate to the health care team about the client. Which element should the nurse cover in the "B" section of the SBAR report?
Mental status
A client has the following arterial blood gas results:Which imbalance would the nurse suspect?pH: 7.33 PaCO2: 42 mm Hg HCO3: 19 mEq/L (19 mmol/L) PaO2: 95 mm Hg
Metabolic acidosis
A nurse is caring for a client who has the following arterial blood gas results: HCO3 18 mEq, PaCO2 28 mmHg and pH 7.30. The nurse recognizes the client is experiencing which of the following acid base imbalances?
Metabolic acidosis
A postoperative client who has been receiving morphine for pain management is exhibiting a depressed respiratory rate and is not responsive to stimuli. Which drug has the potential to reverse the respiratory-depressant effect of an opioid?
Naloxone
A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital signs. Which data collected can be classified as subjective data?
Nausea
A nurse is caring for a young adult female client who has a folic acid deficiency. When educating the client about this condition, the nurse would include a discussion about the client's increased risk for:
Neural tube deficits in the fetus
The following foods are a part of a client's daily diet: high-fiber cereals, fruits, vegetables, ten 8-oz glasses (2,500 mL) of fluids. What would the nurse tell the client to change?
Nothing; this is a good diet
Which consultation or referral by the nurse is most appropriate for a client who is obese and demonstrates poor wound healing?
Nutritional consult
At the end of the shift, the nurse documents that the client has voided 475 mL during the shift via an indwelling urinary catheter. What type of data has the nurse documented?
Objective
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
A nurse calculates the BMI of a client during a general survey as 26. Under which category would this client fall?
Overweight
The nurse would recognize which of these devices as an open drainage system?
Penrose drain
The emergency room nurse is performing an initial assessment of a new client who presents with severe dizziness. The client reports a medical history of hypertension, gout, and migraine headaches. Which step should the nurse take first in the comprehensive assessment?
Perform vital signs and blood glucose level.
A nurse is caring for a client who has had difficulty sleeping. What nursing intervention may facilitate the client's rest?
Providing a back rub before bed
A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client?
Pulse oximetry
A nurse has taken a telephone order from a physician for an emergency medication. The dose of the medication is abnormally high. What should the nurse do next?
Question the order for the medication
The nurse is auscultating breath sounds of an infant with respiratory syncytial virus. For which finding will the nurse immediately contact the health care provider?
Quiet chest from previous assessment of wheezing
A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?
Reduce edema of the brain
A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take?
Remove the catheter and insert another into a different site
A nurse caring for a client who has osteoporosis and takes a daily calcium supplement. Which of the following adverse effects of calcium should the nurse suspect when the client reports having flank pain?
Renal stones
A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22, PaCO2 68 mmHg, Base excess -2, PaO2 78 mmHg, Saturation 80%, Bicarbonate 26 mEq/L
Respiratory acidosis
A client is taking a diuretic that increases her urinary output. What would be an appropriate nursing diagnosis on which to base an educational plan?
Risk for Deficient Fluid Volume
An adolescent tells the nurse that he is afraid his penis will be damaged because he masturbates every day. Which information will the nurse discuss with the client related to masturbation?
Self-stimulation is a normal activity.
A client tells his nurse that he has difficulty hearing related to working in a loud factory setting for 15 years. What is the term for this condition?
Sensory deficit
A client with hearing loss gets very frustrated trying to carry on conversations with friends. Which type of stressor is the client experiencing?
Sensory deficit
A nurse is assessing a client who is taking chlorothiazide sodium. The nurse recognizes which of the following as a manifestation of hypokalemia?
Shallow respirations
A 35-year-old woman is 1 day postpartum. She is reporting moderate perineal pain after giving birth and would like to clean the area. Which method of bathing is most appropriate for this client?
Sitz bath
A nurse is caring for a client with restless leg syndrome who complains of sleeplessness. Which nursing diagnosis is most appropriate for this client?
Sleep Deprivation
A nurse is caring for a client who is receiving morphine via a patient controlled analgesia (PCA) pump. When assessing the client, she notes that his respiratory rate is 4. What should the nurse do first?
Stop the PCA pump.
The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. What is the priority nursing action?
Stop the transfusion.
A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?
Temperature
A hospice nurse is caring for a client who has terminal cancer and takes PO morphine for pain relief. The client reports that he had to increase the dose of morphine this week to obtain pain relief. Which of the following scenarios should the nurse document as the explanation for this situation?
The client developed a tolerance to the medication
A client has been recently diagnosed with diabetes after receiving emergency treatment for a hyperglycemic episode. Which of the client's actions indicates that the client has achieved a cognitive outcome in the management of this new health problem?
The client is able to explain when and why the client needs to check the blood glucose level.
At the beginning of prenatal care, the goal for the client was to gain 25 lb (11.25 kg) by the end of the pregnancy. At 30 weeks of pregnancy, the client has only gained 1 lb (0.45 kg). Which statemen(s) would help the nurse most appropriately interpret these data?
The client is not achieving the goal. The nurse should determine the reasons the client has not been gaining weight.
A resident of a long-term care facility refuses to eat until the client has had hair combed and makeup applied. In this case, what client need should have priority?
The need to feel good about oneself
Which nursing action reflects evaluation?
The nurse assesses the client's response to pain medication.
Which nursing action reflects evaluation?
The nurse assesses urine output following administration of a diuretic.
Which characteristic is the most important indicator of high-quality nursing practice?
The nurse considers the individual needs of clients.
A nurse is caring for a client who had total thyroidectomy and a serum calcium level of 7.6 mg/dL. Which of the following findings should the nurse expect?
Tingling of the extremities
What is the primary purpose of the outcome identification and planning step of the nursing process?
To design a plan of care for and with the client
The husband of a client who died of breast cancer is still grieving for his wife 2 years later. What type of grief is he experiencing?
Unresolved
What is the most common client site for development of healthcare-associated infections (HAI)?
Urinary tract
A new graduate is working at a first job. Which statement is most important for the new nurse to follow?
Use abbreviations approved by the facility.
What intervention is recommended to reduce sensory stimulation for infants in the neonatal ICU?
Use limited light
Which modification to bathing should be implemented for a client who is incontinent?
Use special perineal skin cleaners and moisture barriers.
The nurse has just completed programming of a patient-controlled analgesia (PCA) pump using prescribed parameters. Which action should the nurse take next?
Verify the settings with another nurse.
A nurse working in long-term care facility is assessing residents at risk for the development of a pressure injury. Which resident would be most at risk?
a client 68 years of age who is bedfast related to severe head trauma
To which client would the nurse be most likely to administer a PRN medication?
a client who is reporting pain near the surgical site
Which client would be a candidate for total parenteral nutrition?
a client with colitis and bloody diarrhea
Which client would be classified as having chronic pain?
a client with rheumatoid arthritis
Which client receives a drug that requires a parenteral route?
a woman who has been ordered intravenous antibiotics
Which client would be at greatest risk for injury to the skin and mucous membranes?
man 77 years of age with diabetes
Which are subjective client data gathered during assessment?
nausea , abdominal pain
A female client is asked to provide a specimen for a routine urinalysis. Which instructions should the nurse give the client?
"After cleansing the labia, urinate into the toilet first and then fill the container midstream."
A client is admitted to the mental health center after attempting suicide. Which client concern is the priority for the nurse to manage?
Risk of self harm
A nurse is preparing to administer clindamycin 300 mg by intermittent IV bolus over 30 min to a client who has a staphylococci infection. Available is clindamycin premixed in 50 mL .90% sodium chloride (NaCl). The nurse should set the IV pump to deliver how many mL/hr?
100 mL/hr
A nurse is preparing to administer ticarcillin/clavulanate 3.1 g by intermittent IV bolus over 30 min. Available is ticarcillin/clavulanate 3.1 g in 50 mL 0.9% sodium chloride. The nurse should set the IV pump to deliver how many mL/hr?
100 mL/hr
A nurse is preparing to administer potassium chloride 20 mEq suspension PO daily. The amount available is potassium chloride suspension 10 mEq/mL. How many mL should the nurse administer?
2 mL
Which statement accurately describes a developmental consideration when assessing skin integrity of clients?
An infant's skin and mucous membranes are injured easily and are subject to infection
The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. Which additional assessment would the nurse expect to observe?
Crackles in the lower lobes
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 nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?
Obtain a 12-lead ECG
Which client outcome is an example of a physiologic outcome?
The client's pulse oximetry reading is 97% on room air 30 minutes after removal of a nasal cannula.
An older adult client has constant dribbling of urine. The associated discomfort, odor, and embarrassment may support which nursing diagnosis?
Social isolation
A nurse is providing instruction to a new nurse about caring for clients who are receiving diuretic therapy to treat heart failure. The nurse should explain that which of the following medications puts clients at risk for both hyperkalemia and hyponatremia?
Spironolactone
A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is nurse's priority?
Stopping the transfusion
A nurse uses a catheter to collect a sterile urine specimen from a client at a health care facility. If a catheter is required temporarily, which type of catheter should the nurse use?
Straight catheter
Which is an example of a long-term goal for a client with asthma?
The client will return home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack.
A nurse tells a client, "Are you going to get out of bed, or are you just going to sleep all day and night?" This is an example of which barrier to communication?
Using judgmental or belittling language
A nurse is initiating a 24-hour urine collection for a client at home. What will be the first thing the nurse will ask the client to do at the beginning of the specimen collection?
Void and discard the urine
A client age 61 years has been admitted to a medical unit with a diagnosis of pancreatitis secondary to alcohol use. Which statement by the client suggests that the nurse's teaching has resulted in affective learning?
"I'm starting to see how my lifestyle has caused me to end up here."
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 is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apnea episodes. Which of the following client statements indicates an understanding of the teaching?
"If I could lose about 50 pounds, I might stop having so many apneic episodes"
A client with cancer pain is taking morphine for pain relief. Knowing constipation is a common side effect, what would the nurse recommend to the client?
"Increase fluids and high-fiber foods, and use a mild laxative."
A nurse is reviewing information about the Health Insurance Portability and Accountability Act with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?
"Information about a client can be disclosed to family members at any time"
A nurse touches a client's hand to indicate caring and support. What channel of communication is the nurse using?
Kinesthetic
A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)?
Metabolic alkalosis
A nurse is planning to use the SBAR communication tool when calling a provider. Which of the following statements should the nurse include in the B step?
The client was found unconscious on the floor in her home
A client is prescribed a diuretic for swelling of the lower extremities. What would the nurse teach the client about the effect of the medication on the client's urinary output?
The client's urinary output will be increased.
Which client presents the most significant risk factors for the development of Clostridium difficile infection?
An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis
A nurse has just received a client's laboratory results and is reviewing them. Which finding should the nurse recognize as an indication of malnutrition or malabsorption?
Serum albumin 2.8 g/dL (28 g/L)
An older woman who is a resident of a long-term care facility has to get up and void several times during the night. This can be the result of what physiologic change with normal aging?
diminished ability of the kidneys to concentrate urine
A client who has been on a medication that caused diarrhea is now off the medication. What could the nurse suggest to promote the return of normal flora?
eating fermented products, such as yogurt
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 primary purpose of nursing diagnoses is to
guide selection of nursing interventions to meet expected outcomes.
During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect?
hemolytic transfusion reaction: incompatibility of blood product
A nurse is preparing to administer a medication by intravenous piggyback. Where will the piggyback container be placed?
higher than the primary solution container
A client who is admitted to the health care facility has been diagnosed with cerebral edema. Which intravenous solution needs to be administered to this client?
hypertonic solution
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 nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?
pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mmHg
A nurse is reviewing the arterial blood gas results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see?
pH below 7.35
A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?
removing dead or infected tissue to promote wound healing
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
A school nurse is dealing with an outbreak of pediculosis in an elementary school. Which education points should the nurse prioritize when educating the parents of students who have lice and nits?
the importance of completely finishing the prescribed treatment
A nurse flushes an intravenous lock before and after administering a medication. What is the rationale for this step?
to clear medication and prevent clot formation
A diabetes nurse educator is teaching a client, newly diagnosed with diabetes, about his disease process, diet, exercise, and medications. What is the goal of this education?
to help the client develop self-care abilities
A nurse is administering a medication that is formulated as enteric-coated tablets. What is the rationale for not crushing or chewing enteric-coated tablets?
to prevent gastric irritation
The nurse is caring for a client who speaks very little English, which is the only language the nurse speaks. Until an interpreter arrives, which is an appropriate approach to communicating with this client?
using a caring voice and repeating messages frequently.
A nurse assessing a client's wound documents the finding of purulent drainage. What is the composition of this type of drainage?
white blood cells, debris, bacteria
A student has reviewed a client's chart before beginning assigned care. Which action violates client confidentiality?
writing the client's name on the student care plan
