Basics of Nursing Practice

A client with hypothermia is brought to the emergency department. What treatment does the nurse anticipate when the patient is in the emergency department? 1.Core rewarming with warm fluids 2.Ambulation to increase metabolism 3.Frequent oral temperature assessments 4.Gastric tube feedings to increase fluid volume

1.Core rewarming with warm fluids

When caring for a client who is receiving enteral feedings, the nurse should take which measure to prevent aspiration? 1.Elevate HOB 30-45 degrees. 2.Decrease flow rate at night. 3.Check for residual daily. 4.Irrigate regularly with warm tap water

1.Elevate HOB 30-45 degrees.

After several weeks of caring for clients who are in the terminal stage of illness, the nurse becomes aware of feeling depressed when coming to work. What should the nurse do? 1.Talk with other nurses on the unit. 2.Take several personal days off from work. 3.Limit emotional involvement with the clients. 4.Request a transfer to another area of the hospital.

1.Talk with other nurses on the unit.

A visitor from a room adjacent to a client asks the nurse what disease the client has. The nurse responds, "I cannot discuss any client's illness with you." What legal issue supports the nurse's response? 1.Libel 2.Slander 3.Negligence 4.Invasion of privacy

4.Invasion of privacy

To decrease abdominal distention following a client's surgery, what actions should the nurse take? (Select all that apply.) 1.Encourage ambulation 2.Give sips of ginger ale 3.Auscultate bowel sounds 4.Provide a straw for drinking 5.Offer an opioid analgesic

1.Encourage ambulation 3.Auscultate bowel sounds

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? 1.Evaluation 2.Data Collection 3.Nursing interventions 4.Proposed nursing care

1.Evaluation

A health care provider prescribes a vitamin tablet that contains vitamin B complex. What should the nurse teach the client? 1.It may turn the urine bright yellow. 2.The daily fluid intake should be increased. 3.The drug should be taken on an empty stomach. 4.It may accumulate in the body if an excessive amount is taken

1.It may turn the urine bright yellow.

A complete blood count (CBC), urinalysis, and x-ray examination of the chest are prescribed for a client before surgery. The client asks why these tests are done. Which is the best reply by the nurse? 1."Don't worry; these tests are routine." 2."They are done to identify other health risks." 3."They determine whether surgery will be safe." 4."I don't know; your health care provider prescribed them.

2."They are done to identify other health risks."

Nurses are held responsible for the commission of a tort. The nurse understands that a tort is: 1.The application of force to the body of another by a reasonable individual. 2.An illegality committed by one person against the property or person of another. 3.Doing something that a reasonable person under ordinary circumstances would not do. 4.An illegality committed against the public and punishable by the law through the courts

2.An illegality committed by one person against the property or person of another.

A nurse's co-worker approaches the nurse to inquire about the test results of a friend that is being cared for by the nurse. How should the nurse respond? 1.Answer the questions softly so other people will not hear. 2.Decline to discuss the friend's medical condition. 3.Give the co-worker the name of the client's healthcare provider, so the co-worker can contact the provider instead. 4.To provide reassurance, tell the co-worker of the friend's test results that are within normal limits

2.Decline to discuss the friend's medical condition.

The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia? (Select all that apply.) 1.Dyspnea 2.Flushed face 3.Chest pain 4.Increased pulse rate 5.Increased blood pressure

2.Flushed face 4.Increased pulse rate

A client has seeds containing radium implanted in the pharyngeal area. What should the nurse include in the client's plan of care? 1.Have the client void every two hours. 2.Maintain the client in an isolation room. 3.Spend time with the client to allow verbalization of feelings. 4.Wear two pairs of gloves when touching the client during care

2.Maintain the client in an isolation room.

What are the best ways for a nurse to be protected legally? (Select all that apply.) 1.Ensure that a therapeutic relationship with all clients has been established. 2.Provide care within the parameters of the state's nurse practice act. 3.Carry at least $100,000 worth of liability insurance. 4.Document consistently and objectively. 5.Clearly document a client's non-adherence to the medical regimen

2.Provide care within the parameters of the state's nurse practice act. 4.Document consistently and objectively. 5.Clearly document a client's non-adherence to the medical regimen

A toddler screams and cries noisily after parental visits, disturbing all the other children. When the crying is particularly loud and prolonged, the nurse puts the crib in a separate room and closes the door. The toddler is left there until the crying ceases, a matter of 30 or 45 minutes. Legally, how should this behavior be interpreted? 1.Limits had to be set to control the child's crying. 2.The child had a right to remain in the room with the other children. 3.The child had to be removed because the other children needed to be considered. 4.Segregation of the child for more than half an hour was too long a period of time

2.The child had a right to remain in the room with the other children.

A nurse hired to work in a metropolitan hospital provides services for a culturally diverse population. One of the nurses on the unit says it is the nurses' responsibility to discourage "these people" from bringing all that "home medicine stuff" to their family members. Which response by the recently hired nurse is most appropriate? 1."Hospital policies should put a stop to this." 2."Everyone should conform to the prevailing culture." 3."Nontraditional approaches to health care can be beneficial." 4."You are right because they may have a negative impact on people's health."

3."Nontraditional approaches to health care can be beneficial."

The nurse receives a report on a newly admitted client who is positive for Clostridium difficile. Which category of isolation would the nurse implement for this client? 1.Airborne precautions 2.Droplet precautions 3.Contact precautions 4.Protective environment

3.Contact precautions

What effect of povidone-iodine (Betadine) does a nurse consider when using it on the client's skin before obtaining a specimen for a blood culture? 1.Makes the skin more supple 2.Avoids drying the skin as does alcohol 3.Eliminates surface bacteria that may contaminate the culture 4.Provides a cooling agent to diminish the feeling from the puncture wound

3.Eliminates surface bacteria that may contaminate the culture

An 85-year-old client is alert and able to participate in care. The nurse understands that, according to Erikson, a person's adjustment to the period of senescence will depend largely on adjustment to which developmental stage? 1.Industry versus inferiority 2.Identity versus role confusion 3.Generativity versus stagnation 4.Autonomy versus shame/doubt

3.Generativity versus stagnation

A client with respiratory difficulties asks why the percussion procedure is being performed. The nurse explains that the primary purpose of percussion is to: 1.Relieve bronchial spasm. 2.Increase depth of respirations. 3.Loosen pulmonary secretions. 4.Expel carbon dioxide from the lungs

3.Loosen pulmonary secretions.

What is the priority nursing intervention for a client during the immediate postoperative period? 1.Monitoring vital signs 2.Observing for hemorrhage 3.Maintaining a patent airway 4.Recording the intake and output

3.Maintaining a patent airway

The nurse caring for a client with a systemic infection is aware that the assessment finding that is most indicative of a systemic infection is: 1.White blood cell (WBC) count of 8200/mm3 2.Bilateral 3+ pitting pedal edema 3.Oral temperature of 101.3º F 4.Pale skin and nail beds

3.Oral temperature of 101.3º F

When nurses are conducting health assessment interviews with older clients, they should: 1.Leave a written questionnaire for clients to complete at their leisure 2.Ask family members rather than the client to supply the necessary information 3.Spend time in several short sessions to elicit more complete information from the clients 4.Keep referring to previous questions to ascertain that the information given by clients is correct

3.Spend time in several short sessions to elicit more complete information from the clients

Several recently licensed practical nurses are discussing whether they should purchase personal professional liability insurance. Which statement indicates the most accurate information about professional liability insurance? 1."If you have liability insurance, you are more likely to be sued." 2."Your employer provides you with the liability insurance you will need." 3."Liability insurance is not available for nursing professionals working in a hospital." 4."Personal liability insurance offers representation if the State Board of Nursing files charges against you."

4."Personal liability insurance offers representation if the State Board of Nursing files charges against you."

A nurse working in an emergency department is concerned about a recent increase in malpractice claims against nurses. What is the best way for the nurse to avoid being named in a lawsuit? 1.Carry malpractice insurance. 2.Write vague incident reports. 3.Transfer to another department. 4.Attend professional development programs

4.Attend professional development programs

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with acute bronchopneumonia. The client is in moderate respiratory distress. The nurse should place the client in what position to enhance comfort? 1.Side lying position with head elevated 45 degrees 2.Sim's position with head elevated 90 degrees 3.Semi-Fowler's position with legs elevated 4.High-Fowler's position using the bedside table as an arm rest

4.High-Fowler's position using the bedside table as an arm rest

The nurse is caring for a surgical client who develops a wound infection during hospitalization. How is this type of infection classified? 1.Primary 2.Secondary 3.Superinfection 4.Nosocomial

4.Nosocomial

A client using fentanyl (Duragesic) transdermal patches for pain management in late-stage cancer dies. What should the hospice nurse who is caring for this client do about the patch? 1.Tell the family to remove and dispose of the patch. 2.Leave the patch in place for the mortician to remove. 3.Have the family return the patch to the pharmacy for disposal. 4.Remove and dispose of the patch in an appropriate receptacle

4.Remove and dispose of the patch in an appropriate receptacle

The nurse creates a plan of care for a client with a risk of infection. Which is the most desirable expected outcome for the client? 1.All nursing functions will be completed by discharge. 2.All invasive intravenous lines will remain patent. 3.The client will remain awake, alert, and oriented at all times. 4.The client will be free of signs and symptoms of infection by discharge

4.The client will be free of signs and symptoms of infection by discharge

Ceftriaxone (Rocephin) 2.5 g intravenous piggyback (IVPB) every 8 hours is prescribed for a client with a severe infection. The pharmacy sends a vial labeled 5 g per 10 mL. What volume of ceftriaxone should the nurse add to the IVPB solution? Record your answer using a whole number. __________ mL

5 mL Explaination: Have 5 g 10 mL 5x = 25 x = 25 ÷ 5 x = 5 mL