Basics of nursing practice
A nurse is preparing to give a client a tepid bath and uses a bath thermometer to test the water temperature. What is the acceptable temperature range for a tepid bath?
98 to 100
What physiological changes that occur with aging must be taken into consideration when the nurse provides care for the older adult? (Select all that apply.)
Urinary urgency Loss of skin elasticity Increased b/p
A nurse had difficulty palpating the pedal pulse of a client with venous insufficiency. What action should the nurse take next?
Verify the pulse using a doppler
A client is scheduled for surgery. Legally, the client may not sign the operative consent if:
any sedative type of medication has been given recently
The nurse caring for an older adult client who is aphasic. The client's family reports that the primary nurse failed to obtain a signed consent form before inserting an indwelling catheter to measure I&O. What should the nurse manager consider doing before responding?
A separate signed informed consent for routine treatments is unnecessary
What is a nurse's responsibility when administering prescribed opioid analgesics? (Select all that apply.)
Count the client's respirations Document the intensity of the client's pain. Verify the number of doses in the locked cabinet before administering the prescribed dose.
A client who had an open reduction and internal fixation of a fractured ankle is being discharged. Which behavior indicated the need for further instruction about the use of crutches?
Leaning axillae on the crutches to support the body's weight
A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the nurse question?
Parenteral albumin (Albuminar)
A client is admitted for surgery. Although not physically distressed, the client appears apprehensive and withdrawn. What is the nurse's best action?
Orient the client to the unit environment
The nurse administers a pneumococcal vaccine to a 70 year old client. The client asks "will i have to get this every year like i do with the flu shot?". How should the nurse respond?
"It is unnecessary to have any follow-up injections of the pneumococcal vaccine after this dose."
A client is scheduled for a transurethral resection of the prostate (TURP). Which statement made by the client most indicates the need for further preoperative teaching?
"My incision will probably be painful."
A nurse who is working on a medical-surgical unit receives a phone call requesting information about a client who has undergone surgery. The nurse observes that the client requested a do not publish ("DNP") order on any information regarding condition or presence in the hospital. What is the best response by the nurse?
"We have no record of that client on our unit. Thank you for calling."
Place each step of the nursing process in order
1. obtain clients chart 2. State client's nursing needs 3. Identify goals 4. Develop a plan 5. Implement nursing interventions
Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibit formation of aqueous humor for a client with glaucoma?
AcetaZOLAMIDE (Diamox)
Nurses are held responsible for the commission of a tort. The nurse understands that a tort is:
An illegality committed by one person against the property or person of another
A nurse is taking care of a client who has chronic back pain as a result of a work injury. What nursing considerations should be made when determining the client's plan of care? (Select all that apply.)
Ask the client what is the client's acceptable level of pain Administer the pain medications regularly around the clock
The nurse is having difficulty understanding a client's decision to have hospice care rather than an extensive surgical procedure. Which ethical principle does the client's behavior illustrate?
Autonomy
A 3-year old child sustains multiple fractures in a motor vehicle collision, and casts are applied. The child is admitted for observation to rule out internal injuries. The health care provider asks that vital signs, including blood pressure, be taken every 4 hours. The nurse decides to use the posterior tibial artery to obtain the blood pressure. Mark the extremity where the blood pressure cuff should be positioned to obtain the blood pressure
By the ankle
The nurse recognizes that which are important components of a neurovascular assessment? (Select all that apply.)
Capillary refill Pulse and skin temp Movement and sensation
A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client?
Evaluation
A client reaches the point of acceptance during the stages of dying. What response should the nurse expect the client to exhibit?
Detachment
Immediately after receiving spinal anesthesia a client develops hypotension. To what physiological change does the nurse attribute the decreased blood pressure?
Dilation of blood vessels
An 85 year old client has just been admitted to a nursing home. When designing a plan of care for this older adult the nurse recalls the expected sensory losses associated with aging.
Diminished sensation of pain Impaired hearing of high frequency sounds
Health promotion efforts with the chronically ill client should include interventions r/t primary prevention. What should this include?
Encouraging daily physical exercise
The nurse has provided teaching to a client with impaired balance who uses a walker when ambulating. The nurse observes then client transferring from a sitting to a standing position and using the walker. The nurse evaluates that further teaching is required when the client:
Holds both handles of the walker while rising to the standing position
A client is admitted to the hospital for an elective surgical procedure. The client tells a nurse about the emotional stress of recently disclosing being a homosexual to family and friends. What is the nurse's first consideration when planning care?
Identifying personal feelings toward this client
A client who had a right total hip replacement is progressing from the use of a walker to the use of a cane. In which hand should the nurse teach the client to hold the cane?
Left hand
A client reports severe pain two days after surgery. After assessing the characteristics of the pain, which initial action should the nurse take next?
Obtain V/S
An older African-American client with hypertension is admitted to the hospital. Which data from the client's history and diagnostic workup represent risk factors for hypertension? (select all that apply)
Occasional cocaine use African-American heritage
A client expresses concern about being exposed to radiation therapy because it can cause cancer. What should the nurse emphasize when informing the client about exposure to radiation?
Only a small part of the body is irradiated
What is the most important factor relative to a therapeutic nurse-client relationship when a nurse is caring for a client who is terminally ill?
Personal feelings about terminal illness
When a client files a lawsuit against a nurse for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. This is known as:
Proximate cause
A nurse is providing morning hygiene to a bedridden client who was admitted for exacerbation of chronic obstructive pulmonary disease (COPD). What is the priority nursing intervention when the client becomes short of breath during care?
Put the client in high-fowlers
The nurse should place the client in which position to obtain the most accurate reading of JVD?
Raised to 45 degrees
A nurse educator is presenting info about the nursing process to a class of nursing students. What definition of the nursing process should be included in the presentation?
Sequence of steps used to meet the clients needs
The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this indicates the pulse is:
Full
The nurse is preparing discharge instructions for a client who has begun to demonstrate sx of early Alzheimers. The client lives alone. The client's adult children live nearby. According to the prescribed meds regimen the client is to take meds six times a day. What is priority nursing intervention to assist the client with compliance with med-taking?
Contact HCP and discuss the possibility of simplifying the med regimen
A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? (Select all that apply.)
Pain history including location, intensity and quality of pain Pain pattern including precipitating and alleviating factors
A skier skied off the marked trail into the woods and collided with a tree. After several hours, the skier was found by the ski patrol and brought to the emergency department of the hospital. Moderate hypothermia (temperature range 87 - 90) is diagnosed. What clinical findings specific to moderate hypothermia should the nurse expect the client to exhibit?
Rigidity and slowed respiratory rate
A nurse is planning to transfer a client who is experiencing pain from the bed to a chair. Place the following steps in the order in which they are implemented
1.Verify the client's activity prescription. 2.Identify factors that may impact the ability to transfer. 3.Explain the steps of the transfer. 4.Ensure that the wheels on the bed are locked. 5.Position the client in functional body alignment before transferring
A health care provider prescribes digoxin (Lanoxin) for a client. The nurse teaches the client to be alert for which common early indication of digoxin toxicity?
Nausea
The triage nurse in the emergency department receives four clients simultaneously. Which of the clients should the nurse determine can be treated last?
Older adult male with a partially amputated finger
