ADULT Exam 1
A client scheduled for surgery has been taking aspirin since his heart attack in 1997. The client is at risk for:
hemorrhage (p. 980)
A nurse is caring for a client in the same-day surgery unit. The client asks the nurse, "Do I really need to be put to sleep for this surgery?" Which would be the nurse's best response?
"tell me what you're most worried about" (p. 947)
The nurse is talking with a client who wishes to have a tattoo removed. Which client statement indicates that the client understands how the procedure will be accomplished?
"the provider will perform this laser surgery in an ambulatory care setting" (p. 940)
The client is taking continuous-release oxycodone for chronic pain and now reports constipation. What should be the first question the nurse asks the client?
"when was your last bowel movement?" (p. 242)
A nurse consults with a nurse practitioner trained to perform acupressure to teach the method to a client being discharged. What process is involved in this pain relief measure?
(p. 1253)
The wife of a client with cancer is concerned that her husband's breakthrough doses of morphine have recently needed to be larger and more frequent in order for him to achieve pain relief. The nurse would recognize that the client is likely showing the effects of:
(p. 1256)
Which client statements would indicate to the nurse that the client needs additional teaching regarding prn pain medication and management? Select all that apply.
-"I should wait until my pain gets worse before asking for pain medications." -"It's better to put up with the pain than deal with side effects of medication." -"If I ask for pain medication, I may become addicted." -"The nurse will know when my medication is due and will give it to me automatically." (p. 1259)
Which question is most important for the nurse to ask the client when obtaining the preoperative admission history?
"When is the last time you ate or drank? (p. 431)
The nurse is caring for a client after breast augmentation. Before performing a bowel assessment, what education will the nurse provide the client?
"You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or narcotics. By listening for bowel sounds, I can check for a return of peristalsis." (p. 964)
A nurse is planning preoperative teaching for an older client. Which structural or functional changes in the older adult impact the surgical experience? Select all that apply.
-Increased fatty tissue prolongs elimination of anesthesia. -Decreased ability to compensate for hypoxia increases the risk of an embolism. -Loss of collagen increases the risk of skin complications. -Reduced tactile sensitivity can lead to assessment and communication problems (p. 419-420)
A nurse is documenting evaluation of the care provided for an infant born with Down syndrome. Which nursing actions exemplify the appropriate documentation process? Select all that apply.
-after the data have been collected to determine client outcome achievement, the nurse writes an evaluative statement to summarize the findings -the nurse writes a 2-part evaluative statement that includes a decision about how well the outcome was met, along with client data that supports the decision -the nurse has three decision options for how goals have been met (p. 440)
The nurse is caring for a client who has had abdominal surgery. Which intervention(s) will the nurse include to prevent complications for this client? Select all that apply.
-assist the client with the use of incentive spirometry -turn the client and change position frequently -administer analgesic medication as required (p. 396)
A terminally ill client asks the nurse "Am I dying?" The family has asked the health care team not to disclose the client's terminal illness. What is the best action by the nurse with the client's question?
-communicate the client's wishes to the family -consult with the health care provider -provide correct information to the client (p. 32)
What does the nurse expect to be included in the directions for reconstitution on a drug label?
-dosage per volume after reconstitution -amount of diluent to be added -directions of storing the drugs (p. 849)
The physician requests lidocaine 2% with epinephrine for use in local infiltration anesthesia. What does the nurse understand is the purpose of adding epinephrine to the lidocaine?
-epinephrine causes vasoconstriction -epinephrine prevents rapid absorption of the anesthetic drug -epinephrine prolongs the local action of the anesthetic drug
A nurse is administering a subcutaneous injection to a client. What is the common maximum volume of a subcutaneous injection?
1 mL (p. 849)
A client having a surgical procedure takes aspirin 325 mg daily for prevention of platelet aggregation. When should the client stop taking the aspirin before the surgery?
7-10 days (p. 426)
Which surgical client does the nurse in the preoperative setting anticipate having the greatest potential for surgical complications?
76 year old client with a history of renal failure and chronic bronchitis (p. 945)
What is the blood glucose level goal for a diabetic client who will be having a surgical procedure?
80-110 mg/dL (p. 426)
What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period?
< 30mL (p. 467)
The nurse understands that which of the following physiologic changes that influence the pain response occur in the gerontologic population?
increased sensitivity to medications (p. 244)
A nurse is working as a registered nurse first assistant as defined by the state's nurse practice act. This nurse practices under the direct supervision of which surgical team member?
surgeon (p. 438-439)
A client is scheduled for hip replacement surgery this morning but admits to the nurse that he had a small piece of toast and some water after waking up. What is the nurse's most appropriate response?
inform the anesthesiologist or surgeon of this fact (p. 955)
When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as...
emergency (p. 421)
A gunshot wound would be classified under which category of surgery based on urgency?
emergent (p. 421)
Informed consent from the surgical client is essential in all of the following categories of surgery except:
emergent surgery (p. 422)
The nurse is educating a client who is preparing for abdominal surgery tomorrow. A teaching demonstration has just been completed by the nurse related to splinting the incision site with a pillow. Which statement by the client best indicates the instructions provided by the nurse were effective?
I will put the pillow on the incision then cough
A nurse is teaching a client about pain management after surgery. Which client statement indicates the teaching was effective?
I will support my incision with my hands when I cough and do my deep breathing exercises (p. 429)
which route of administration of medication is preferred in the most acute care situations?
IV (p. 233)
A client in pain believes that the pain is a punishment from God, and feels angry and resentful. Which is the most appropriate action by the nurse?
encourage a client to confer with a spiritual advisor (p. 1242)
Which client in the postanesthesia care unit (PACU) requires the most immediate attention by the nurse?
a 26 year old client who is exhibiting a crowing sound (p. 944)
Which client would most likely require placement of a implantable port?
a 58 yr old woman with stage 3 breast cancer requiring chemotherapy (p. 833)
the nurse is reviewing the plan of care for several clients who have prescriptions for IV meds. The nurse understands that which client is at the highest risk for great effect of the IV medication?
a 73 yr old client with liver disease (p. 825)
The nurse expects informed consent to be obtained for insertion of:
a gastrostomy tube (p. 422)
A pregnant client asks the nurse for information on breastfeeding. What type of nursing diagnosis should the nurse formulate?
a health promotion of nursing diagnosis (p. 367)
Which client most likely requires special preoperative assessment and treatment as a result of the existing medication regimen?
a woman who takes daily anticoagulants to treat atrial fibrillation (p. 946)
A nurse is caring for a toddler who has been treated on two different occasions for lacerations and contusions due to the parents' negligence in providing a safe environment. What is an appropriate nursing diagnosis for this client?
high risk for injury related to unsafe home environment (p. 372)
A nurse is conducting an interview with a client. Which example best demonstrates use of open-ended questions in an interview?
how are you feeling? (p. 351)
The nurse is performing a preoperative assessment of a client who has been scheduled for a reduction mammoplasty (breast reduction). The client states, "I'm starting to wonder if I made the right decision in going ahead with this." What should the nurse do next?
explore the client's feelings and inform the surgeon (p. 968-973)
The nurse is concerned that a postoperative patient may have a paralytic ileus. What assessment data may indicate that the patient does have a paralytic ileus?
absence of peristalsis (p. 472)
The nurse is developing a plan of care for a client with a fractured femur who is in traction and will be restricted to bed for some time. Which domain should the nurse consider when developing a nursing diagnosis based on this client's musculoskeletal health problems?
activity and rest (p. 323)
The nurse recognizes that health problems that the nurse can address by independent nursing interventions are called:
actual or potential nursing diagnoses (p. 367)
Acute pain can be distinguished from chronic pain by assessing which characteristic?
acute pain is specific and localized (p. 225)
The nurse is caring for a group of clients. What priority nursing intervention illustrates planned nursing prioritized according to maslow's hierarchy of needs?
administer pain meds to a client before transportation to physical therapy for crutch-walking exercise
Clients who have received corticosteroids preoperatively are at risk for which type of insufficiency?
adrenal (p. 426)
Which client situation most likely warrants a time-lapse nursing assessment?
an older adult resident of an extended care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit (p. 342)
A patient is scheduled for a surgical procedure. For which surgical procedure should the nurse prepare an informed consent form for the surgeon to sign?
an open reduction of a fracture (p. 422)
A nurse is educating a pregnant client in preterm labor on the use of the client's home monitoring equipment and medications. Which factor could impede the client's ability to learn?
anxiety (p. 194)
When should the nurse encourage the postoperative patient to get out of bed?
as soon as indicated (p. 466)
A nurse is teaching a client about the rationale for fasting from food and fluids prior to surgery. What condition does this measure attempt to avoid?
aspiration
A nurse is teaching a client about the rationale for fasting from food and fluids prior to surgery. What condition does this measure attempt to avoid?
aspiration (p. 968-973)
A client who fell at home is hospitalized for a hip fracture. The client is in Buck's traction, anticipating surgery, and reports pain as "2" on a pain intensity scale of 0 to 10. The client also exhibits moderate anxiety and moves restlessly in the bed. The best nursing intervention to address the client's anxiety is to...
assess the reason for the client's anxiety (p. 245)
A client is postoperative day 3 after surgical repair of an open abdominal wound and traumatic amputation of the right lower leg following a motorcycle crash. What is the highest priority nursing intervention?
assessing WBC count, temperature, wound appearance (p. 474)
The correct progression of steps of the nursing process is:
assessment, diagnosis, planning, implementation, evaluation (p. 316)
The nurse is caring for a client in the hospital who has been taking an analgesic for pain related to a chronic illness and has developed a tolerance to the medication. What is the most appropriate action by the nurse?
consult with the prescriber regarding the need for an increased dose of the drug and not to reduce the frequency of administration (p. 238)
Which is the best source of information for the nurse when collecting data for an assessment?
client (p. 347)
Which of the following nursing interventions contributes to achieving a client's pain relief?
collaborate with the client about his or her goal for a level of pain relief (p. 232)
The physician has ordered a mu opioid analgesic for a patient with pain. What drug does the nurse anticipate administering?
fentanyl (p. 236)
Priority setting is based on the information obtained during reassessment and is used to rank nursing diagnoses. Each factor contributes to priority setting except which?
finances of the client (p. 419)
A patient with uncontrolled diabetes is scheduled for a surgical procedure. What chief life-threatening hazard should the nurse monitor for?
hypoglycemia (p. 426)
The home health nurse is performing an assessment related to the client's ability to manage activities of daily living in the home environment. Which assessment is the nurse performing?
functional assessment (p. 698)
The primary purpose of nursing implementation is to:
help the client achieve optimal levels of health (p. 414)
The LPN is collaborating with the RN in developing a plan of care for a new client. Which description of nursing roles best describes the LPN's contribution to the plan?
data gathering, id of client strengths, assurance of client safety during the assessment phase (p. 36)
A 70-year-old patient who is to undergo surgery arrives at the operating room (OR). The nurse, when reviewing the patient's medical record, understands that this patient will require a lower dose of anesthetic agent because of which of the following?
decreased lean mass tissue (p. 437)
A client with an abdominal surgical wound sneezes and then states, "Something doesn't feel right with my wound." The nurse asses the upper half of the wound edges, noticing that they are no longer approximated and the lower half remains well approximated. The nurse would document that following a sneeze, the wound
dehisced (p. 474)
A nurse is reinforcing wound edges and applying a blinder to the separated incisions of a client after a surgery. Which postoperative complication has the client developed?
dehiscence (p. 964)
The nurse is developing a client's care plan. What activity best exemplifies the assessment phase of the nursing process?
determine the client has a pulse rate of 88 bpm (p. 35)
The nurse is assessing a patient complaining of severe pain. What physiologic indicator does the nurse recognize as significant of acute pain?
diaphoresis (p. 226)
While providing a back massage, the nurse observes a reddened area on the client's sacral area. Which action by the nurse is appropriate?
document the finding (p. 1271-1274)
Which is the priority question for the nurse to consider before implementing a new intervention?
does this treatment make sense for this client? (p. 419)
The nurse is supervising a nursing student who is providing postoperative education to a client with an abdominal incision. The nurse sees the student coaching the client to perform coughing exercises, as pictured above. What is the nurse's best action?
instruct the student to provide the client with a pillow or folded blanket to hug (p. 953)
A client asks why a drain is in place to pull fluid from the surgical wound. What is the best response by the nurse?
it assists in preventing infection (p. 469)
Which surgical clients will return to activities in their everyday lives more quickly?
laparoscopic cholecystectomy (p. 939)
The nurse understands that the purpose of the "time out" is to:
maintain the safety of the client (p. 438)
The nurse cares for a client following surgery to repair an abdominal aortic aneurysm. Which nursing intervention assists with healing and maintaining client comfort?
maintaining a calm environment (p. 960)
The nurse-anesthetist is monitoring the client during surgery. He notices a ventricular dysrhythmia and unstable blood pressure. He notifies the surgeon. The operative team suspects:
malignant hyperthermia (p. 959)
During surgery a patient develops hypothermia. The circulating nurse would monitor the patient closely for which of the following?
metabolic acidosis (p. 450)
A postoperative client is moving from the bed to a chair when blood drips from the dressing. The nurse assesses the incision and notes evisceration. What does the nurse do first?
moisten sterile gauze with sterile saline and place on the protruding organ (p. 475)
Hypothermia may occur as a result of
open body wounds (p. 450)
Fentanyl is categorized as which type of intravenous anesthetic agent?
opioid (p. 446)
Which measure would the nurse implement for prevention of deep vein thrombosis (DVT) in a postoperative client?
place graduated compression stockings on the client (p. 970)
A 9-month-old baby is scheduled for heart surgery. When preparing this client for surgery, the nurse should consider which surgical risk associated with infants?
potential for hypothermia or hyperthermia (p. 944)
As a circulating nurse caring for a 45-year-old man undergoing left knee arthroscopic exploratory surgery, which task ensures that the team is on the same page and will perform the procedure on the right client and at the right site?
procedural pause (time-out) (p. 956)
What complication is the nurse aware of that is associated with deep venous thrombosis?
pulmonary embolism (p. 473)
The nurse recognizes which symptom as a clinical manifestation of shock?
rapid, weak, thready pulse (p. 459)
A nurse is teaching a client about deep venous thrombosis (DVT) prevention. What teaching would the nurse include about DVT prevention?
report early calf pain (p. 473)
A nurse is witnessing a client sign the consent form for surgery. After signing the consent form, the client starts asking questions regarding the risks and benefits of a surgical procedure. What action by the nurse is most appropriate?
request that the surgeon come and answer the questions (p. 422)
The nurse is caring for a confused older adult client who requires surgery for a broken hip. What steps does the nurse take to determine if the client has a durable power of attorney for health care and how to contact that person?
review the medical chart for a copy of a durable power of attorney for health care or permission for disclosure contact (p. 941)
The client is undergoing a surgical procedure that is expected to last several hours. Which nursing diagnosis is most related to the duration of the procedure?
risk for perioperative positioning injury related to positioning in the OR (p. 452)
A client receiving moderate sedation for a minor surgical procedure begins to vomit. What should the nurse do first?
roll the client onto his or her side (p. 450)
A client is undergoing thoracic surgery. What priority education should the nurse provide to assist in preventing respiratory complications?
splint the incision site using a pillow during deep breathing and coughing exercises (p. 429)
Which of the following is the only reliable source for quantifying pain?
the client (p. 225)
When does the nurse understand the patient is knowledgeable about the impending surgical procedure?
the patient participates willingly in the preoperative preparation (p. 429)
The nurse recognizes that palliative surgery is performed for what purpose?
to lessen the intensity of an illness (p. 980)
A nurse from the ambulatory surgical center is preparing discharge instructions for a client who has had pelvic surgery. Which criterion would the client need to demonstrate to ensure that she is ready for discharge?
void normally (p. 965)
Which of the following is an inappropriate nursing action by the surgical nurse?
wearing sterile gloves over artificial nail (p. 441)
Which nursing actions promote safety in the preparation of medicine?
-prepare meds in well-lit conditions -return medications with obscured labels to the pharmacy -note the expiration dates on liquid medications (p. 874)
At what point does the preoperative period end?
When the client is transferred onto the operating table (p. 419)
A new mother is having difficulty breastfeeding a newborn infant. A goal was established stating that the baby would be nursing every 2 to 3 hours by age 1 week. The mother presents to the follow-up center at 1 week and reports having discontinued breastfeeding. The nurse evaluates the original goal as:
completely unmet (p. 443)
What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?
nurses do carry out interventions in response to a physician's order (p. 397)
Which of the following is a disadvantage to using the IV route of administration for analgesics?
short duration (p. 233)
A nurse works for a facility that does not utilize modified safety injection equipment. How will the nurse prevent needlesticks?
-scoop the cap back onto a used needle with one hand without touching the cap -leave the needle uncapped and dispose of it in the nearest biohazard container (p. 846)
A physician orders morphine sulfate 1 mg IV stat for chest pain. The drug is available in 2 mg per 1 mL syringe. How many mL does the nurse administer? Enter the correct number ONLY.
0.5 (p. 238)
The nurse is preparing to administer an allergy test intradermally. At what angle will the nurse plan to insert the needle into the client?
10-15 degrees (p. 849)
The nurse is preparing to administer two IV medications. What is the appropriate nursing action?
Consult a current drug reference book for IV compatibility (p. 848)
The nurse is teaching a client with heart failure about taking digoxin safely. Which statement by the client indicates teaching was effective?
I will call the health provider if I experience dizziness, blurred vision, nausea (p. 857-859)
A client is scheduled for a surgical procedure. When planning the client's care, the nurse should consider that which of the following conditions will increase the client's risk of complications after surgery?
a history of diabetes (p. 426)
The nurse caring for a client with obesity would like to address the possible health problems that can develop related to obesity. To plan care for this client, what type of nursing diagnosis would the nurse formulate?
a risk nursing diagnosis (p. 373)
The nurse is preparing to administer an enteric-coated aspirin to a client. The client states, "I cannot swallow that so you will have to crush it and put it in applesauce for me as the other nurse does." Which is an appropriate reply from the nurse?
crushing the whole medication may cause the medication to irritate the stomach, so it must be swallowed whole (p. 841-843)
Which substance reduces the transmission of pain?
endorphins
Which source of information helps the nurse formulate nursing diagnoses for a specific client?
essential assessment data (p. 35)
Which term is defined as a formal systematic study of moral beliefs?
ethics (p. 30)
The nurse is preparing to conduct an assessment on a new client of Chinese descent who is being admitted for abdominal surgery. Which step should the nurse prioritize during the assessment with this client?
explain the nurse will need to touch the client during the assessment (p. 152, 169)
A nurse is caring for a client with pain. What should the nurse monitor for when administering intravenous acetaminophen?
hepatotoxicity (p. 235)
About which issue should the nurse inform clients who use pain medications on a regular basis?
inform the primary health care provider about the use of salicylates before any procedure and avoid otc analgesics consistently w/o consulting a physician
The nurse is preparing to administer an allergy test via intradermal. Which injection site would be most appropriate?
inner surface of the forearm (p. 890-894)
When drafting a nursing care plan for a patient in pain, it is important for the nurse to determine if the pain is acute or chronic. Choose the best example of chronic pain.
intervertebral disk herniation (p. 225-226)
The nurse recognizes that identifying outcomes/goals must include:
involvement of the client and family (p. 389)
Patient health education provided by the nurse...
is an independent function of nursing practice (p. 40)
Which statement best explains why continuing data collection is important?
it enables the nurse to revise the care plan appropriately (p. 428)
Which of the following is a true statement about critical thinking according to Alfaro-LeFevre?
it is guided by professional standards and codes of ethics (p. 29)
According to The Joint Commission's pain assessment and management standards, which of the following are essential components of a comprehensive pain assessment?
location, onset, alleviating factors, and aggravating factors (p. 230)
A client has an order for for an intermittent infusion of 250 mL of 0.9 normal saline. The nurse understands that this type of infusion is used for what situation?
medications that need to be infused over 20-60 mins (p. 856)
The nurse is caring for a client with a yeast infection. Which medication does the nurse anticipate will be prescribed?
miconazole (p. 862)
An 87-year-old client has been admitted to the hospital several times in the past few months for exacerbations of chronic obstructive pulmonary disease and elevated blood glucose levels. Which statement by the client could help identify the most likely reason for the changes in the client's health status?
my wife's been gone for about 7 months now (p. 417-429)
A 16-year-old client was admitted to the medical unit 1 hour ago for sickle cell crisis. Vital signs are as follows: temperature, 98.24°F (36.8°C) sublingual; heart rate, 95 beats/min; respiratory rate, 20 breaths/min; blood pressure, 130/65 mm Hg. The client rates pain as a 9/10. The nurse is talking with the medical resident on service to discuss client orders. Which order is the nurse likely to request first for the client?
narcotic analgesic to treat pain (p. 389-390)
A client has a long history of diabetes mellitus and developed diabetic neuropathy more than 25 years ago. The client is without breakthrough pain at this point in time. How would this client's pain be classified?
neuropathic and chronic (p. 229)
When administering heparin subcutaneously the nurse should:
never aspirate (p. 925)
The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action?
notify the physician for additional orders (p. 364-365)
A nurse is reading a journal article about providing individualized care. Which aspect would the nurse most likely read about as the almost universally accepted method for providing nursing care?
nursing process (p.316-318)
The nurse is assessing an older adult patient just admitted to the hospital. Why is it important that the nurse carefully assess pain in the older adult patient?
older people experience reduced sensory perception (p. 244)
A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on the client's activities of daily living (ADLs) during the period of recovery. When should the nurse begin discharge planning to address this client's ADLs?
on the client's admission to the hospital (p. 390)
A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based on improvements in the client's condition. This is an example of which type of planning?
ongoing (p. 390)
A client is receiving morphine through a patient-controlled analgesia (PCA) system following surgery. The nurse states to the client...
only you are to push the button for medication (p. 234)
The nurse is administering a rectal suppository. How far will the nurse insert it?
past the internal sphincter (p. 864)
Which phase of pain transmission occurs when the brain experiences pain at a conscious level?
perception (p. 229)
A mother brings an infant into the clinic. The infant is 2 months old and has not been gaining weight appropriately. The outcome statement on the plan of care states, "The infant will double birth weight by 6 months of age." This is an example of which type of outcome statement? You Selected:
physical changes (p. 451)
Which is a true statement regarding placebos?
placebos should never be used to test a client's truthfulness about pain (p. 245)
Developing a written plan of nursing care takes place during which step of the nursing process?
planning (p. 39)
The nurse has measured from the tip of the client's nose to the earlobe and then down to the xiphoid process before inserting a nasogastric (NG) tube and attaching it to low suction. Which components of the nursing process has the nurse demonstrated?
planning; implementing (p. 316)
The nurse is reviewing the pre-admission laboratory findings of the client scheduled for surgery. Which laboratory value would be of greatest concern to the nurse?
potassium 6.2 mEq/L (p. 423)
When is the ideal time to discuss preoperative teaching
preadmission visit (p. 428)
A nurse documents the presence of chronic pain on an electronic health record. Choose a description that could be used. The pain can be:
prolonged in duration (p. 225)
Which type of nursing diagnosis identifies potential problems that may arise due to the client's disease, condition, situation?
risk (p. 38)
The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. To promote the health of the family members, what would be the most important information for the nurse to include?
risk factors for and prevention of diabetes mellitus (p. 419)
An acute care facility follows the unit dose supply method to supply medication to the clients. What is meant by the unit dose supply method?
self-contained packets that hold one tablet or capsule for individual clients (p. 834)
The nurse is preparing to administer nasal medication via a dropper to a client with severe congestion. Into which position will the nurse place the client?
supine (p. 863)
A client is scheduled for abdominal surgery and states that he is afraid of postoperative pain. The best nursing action is to inform the client...
that medication will be prescribed for pain relief (p. 232)
A client reports abdominal pain as "8" on a pain intensity scale of 0-10 thirty minutes after receiving an opioid intravenously. Her past medical history includes partial-thickness burns to approximately 60% of her body several years ago. The nurse assesses...
that the client's past experiences with pain may influence her perception of current pain (p. 232)
An elderly client who enjoyed watercolor painting when young has recently indicated a desire to begin painting again. According to Maslow's theories on human needs, what is the best reason the client will express an interest in painting again?
the client is motivated for creative expression because lower level needs are being met (p. 5)
Regarding medication administration, what must occur at the change of shifts?
the narcotics for the division are counted (p. 839)
The nurse needs to carefully monitor a client with traumatic injuries. Which action by the nurse demonstrates understanding of the most essential component of the client's pain assessment?
the nurse administers pain medication based on the client's reported pain level (p. 230)
which characteristic is the most important indicator of high-quality nursing practice?
the nurse considers the individual needs of the client (p. 448)
The nurse has developed a plan of care for a client who is having a surgical procedure and is at risk for the development of pneumonia. The nurse devises the outcome statement to read: "The client will have clear lungs by the third postoperative day. " On the third postoperative day, the client has left lower lobe crackles and infiltrates on the chest x-ray. What conclusion does the nurse reach for this client?
the outcome is not achieved and the plan requires critical reevaluation and revision (p. 41)
A nurse chooses a quiet, private area to conduct an end-of-shift report to the oncoming nurse. Following this procedure is necessary because of what ethical problem in nursing?
the right of confidentiality is essential to protect each client's private info (p. 33)
An example of a curative surgical procedure is...
tumor excision (p. 419)
A client is admitted with generalized abdominal pain, nausea, vomiting, and hypotension. The client has not passed stool in over 1 week and has been in pain for the past 4 days. Which type of pain would you expect the client to be experiencing?
visceral (p. 227)
The nurse is caring for a client with kidney stones who is complaining of severe pain. What type of pain does the nurse understand this client is experiencing?
visceral pain (p. 227)
