Basics of Nursing Practice

Immediately after receiving spinal anesthesia a client develops hypotension. To what physiological change does the nurse attribute the decreased blood pressure? 1.Dilation of blood vessels 2.Decreased response of chemoreceptors 3.Decreased strength of cardiac contractions 4.Disruption of cardiac accelerator pathways

1.Dilation of blood vessels

When providing care for a client with a nasogastric (NG) tube, the nurse should take measures to prevent what serious complication? 1.Skin breakdown 2.Aspiration pneumonia 3.Retention ileus 4.Profuse diarrhea

2.Aspiration pneumonia

A 2-g sodium diet is prescribed for a client with stage 2 hypertension, and the nurse teaches the client the rationale for this diet. The client reports distaste for the food. The primary nurse hears the client request that the family "bring in a ham and cheese sandwich and fries." What is the most effective nursing intervention? 1.Discuss the diet with the client and family. 2.Tell the client why salty foods should not be eaten. 3.Explain the dietary restriction to the client's visitors. 4.Ask the dietitian to teach the client and family about sodium restrictions

1.Discuss the diet with the client and family.

A nurse is assisting a client to transfer from the bed to a chair. What should the nurse do to widen the client's base of support during the transfer? 1.Spread the client's feet away from each other. 2.Move the client on the count of three. 3.Instruct the client to flex the muscles of the internal girdle. 4.Stand close to the client when assisting with the move

1.Spread the client's feet away from each other.

During an admission assessment the nurse discovers that a client has a stage 1 pressure ulcer. Which is the priority nursing action? 1.Turn and reposition the client every 2 hours. 2.Cover the ulcer with an occlusive transparent dressing. 3.Clean the ulcer with hydrogen peroxide and leave it open to the air. 4.Provide the client with a diet high in vitamin C, zinc, and protein.

1.Turn and reposition the client every 2 hours.

What is a nurse's most appropriate response, based on current research, when asked about spanking as a disciplinary technique? 1."Effectiveness depends on the child's age." 2."Spanking is strongly suggestive of negative role modeling." 3."Spanking may be the only option when no other technique works." 4."Research studies have shown it to be an effective disciplinary technique.

2."Spanking is strongly suggestive of negative role modeling."

When changing the soiled bed linens of a client with a wound that is draining seropurulent material, what personal protective equipment (PPE) is most essential for the nurse to wear? 1.Mask 2.Clean gloves 3.Sterile gloves 4.Shoe covers

2.Clean gloves

When caring for a client with pneumonia, which nursing intervention is the highest priority? 1.Increase fluid intake. 2.Employ breathing exercises and controlled coughing. 3.Ambulate as much as possible. 4.Maintain an NPO status.

2.Employ breathing exercises and controlled coughing.

A nurse is caring for a client on bed rest. How can the nurse help prevent a pulmonary embolus? 1.Limit the client's fluid intake. 2.Teach the client how to exercise the legs. 3.Encourage use of the incentive spirometer. 4.Maintain the knee gatch position at an angle

2.Teach the client how to exercise the legs.

The nurse is preparing discharge instructions for a client that acquired a nosocomial infection, Clostridium difficile. What should the nurse include in the instructions? 1.Anticipate that nausea and vomiting will continue until the infection is no longer present. 2.The infection causes diarrhea accompanied by flatus and abdominal discomfort. 3.Consume a diet that is high in fiber and low in fat. 4.Other than routine handwashing, it is not necessary to perform special disinfection procedures

2.The infection causes diarrhea accompanied by flatus and abdominal discomfort.

A home health nurse checks the client's vital signs and completes a follow- up visit. After completion of these tasks, the client asks the nurse to straighten the blankets on the bed. What is the nurse's most appropriate response? 1."I would, but my back hurts today." 2."Okay. It will be my good deed for the day." 3."Of course. I want to do whatever I can for you." 4."I would like to, but it is not in my job description."

3."Of course. I want to do whatever I can for you."

A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. This assessment should be documented as: 1.Vesicular 2.Bronchial 3.Crackles 4.Rhonchi

3.Crackles

A nurse is preparing a community health program for senior citizens. The nurse teaches the group that the physical findings that are typical in older people include: 1.A loss of skin elasticity and a decrease in libido 2.Impaired fat digestion and increased salivary secretions 3.Increased blood pressure and decreased hormone production 4.An increase in body warmth and some swallowing difficulties

3.Increased blood pressure and decreased hormone production

A nurse has provided discharge instructions to a client who received a prescription for a walker to use for assistance with ambulation. The nurse determines that the teaching has been effective when the client: 1.Picks up the walker and carries it for short distances. 2.Uses the walker only when someone else is present. 3.Moves the walker no more than 12 inches in front of the client during use. 4.States that a walker will be purchased on the way home from the hospital

3.Moves the walker no more than 12 inches in front of the client during use.

The nurse should place the client in which position to obtain the most accurate reading of jugular vein distention? 1.Upright at 90 degrees 2.Supine position 3.Raised to 45 degrees 4.Raised to 10 degrees

3.Raised to 45 degrees

A nurse suspects that a client has poison ivy. Assessment findings reveal vesicles on the arms and legs. A vesicle can be described as: 1.A lesion filled with purulent drainage. 2.An erosion into the dermis. 3.A solid mass of fibrous tissue. 4.A lesion filled with serous fluid

4.A lesion filled with serous fluid

A dying client is coping with feelings regarding impending death. The nurse bases care on the theory of death and dying by Kübler-Ross. During which stage of grieving should the nurse primarily use nonverbal interventions? 1.Anger 2.Denial 3.Bargaining 4.Acceptance

4.Acceptance

A nurse is discussing Alcoholics Anonymous (AA) with a client. What behavior expected of members of AA should the nurse include in the discussion? 1.Speaking aloud at weekly meetings 2.Promising to attend at least 12 meetings yearly 3.Maintaining controlled drinking after six months 4.Acknowledging an inability to control the problem

4.Acknowledging an inability to control the problem

A terminally ill client is furious with one of the staff nurses. The client refuses the nurse's care and insists on doing self-care. A different nurse is assigned to care for the client. What should be the newly assigned nurse's initial step in revising the client's plan of care? 1.Get a full report from the first nurse and adjust the plan accordingly. 2.Ask the health care provider for a report on the client's condition and plan appropriately. 3.Tell the client about the change in staff responsibilities and assess the client's reaction. 4.Assess the client's present status and include the client in a discussion of revisions to the plan of care

4.Assess the client's present status and include the client in a discussion of revisions to the plan of care

When being interviewed for a position as a licensed practical nurse, the applicant is asked to identify an example of an intentional tort. What is the appropriate response? 1.Negligence 2.Malpractice 3.Breach of duty 4.False imprisonment

4.False imprisonment

A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency? (Select all that apply.) 1.Diplopia 2.Skin rash 3.Leg cramps 4.Tachycardia 5.Muscle weakness

4.Tachycardia 5.Muscle weakness

Following a surgery on the neck, the client asks the nurse why the head of the bed is up so high. The nurse should tell the client that the high-Fowler position is preferred for what reason? 1.To avoid strain on the incision 2.To promote drainage of the wound 3.To provide stimulation for the client 4.To reduce edema at the operative site

4.To reduce edema at the operative site