CORE PRACTICE

1. The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic and crackles are audible on auscultation. What additional signs would the nurse expect to note in this client if excess fluid volume is present?

a. Weight loss b. Flat neck veins c. An increase in blood pressure.... d. Decreased central venous pressure

In an ongoing assessment the nurse should identify the client's thoughts and feelings about a situation in addition to what other factors?

Whether the client's behavior is appropriate in the context of the current situation ..... b. Whether the client is motivated to decrease dysfunctional behaviors c. Which of the client's problems have the highest priority d. Which of the client's behaviors necessitates a no-harm contract Assessment examines the client's thoughts, feelings, and behaviors within a context. Whether the client's behavior is appropriate for the situation is important assessment data.

1. During a home visit, a client who is 75 years old tells the community health nurse, "Lately I am getting forgetful about things. For one thing, I cannot remember names. Do you think I am getting Alzheimer's disease?" Which response by the nurse is best?

a. "It is normal for people your age to forget things such as names." b. "I do the same thing. Sometimes I can't remember someone's name either." c. "Tell me more about your forgetfulness. It is not unusual for forgetfulness to occur."...... d. "Most people your age have this problem. It is not Alzheimer's disease."

1. A client with an extracapsular hip fracture returns to the nursing unit after internal fixation and pin insertion with a drainage tube at the incision site. Her husband asks, "Why does she have this tube inserted in her hip?" Which response would be best?

a. "The tube helps us to detect a wound infection early on." b. "This way we will not have to irrigate the wound." c. "Fluid will not be allowed to accumulate at the site.".... d. "We have a way to administer antibiotics into the wound."

1. The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?

a. A client scheduled for a chest x-ray b. A client requiring daily dressing changes c. A postoperative client preparing for discharge d. A client receiving nasal oxygen who had difficulty breathing during the previous shift.......

1. A client with end-stage chronic renal failure is admitted to the hospital with a serum potassium level of 7 mEq/L. in what order of priority from first to last does the nurse perform the prescriptions?

a. Administer calcium gluconate (3) b. Start an IV access site (1) c. Administer sodium polystyrene sulfonate (4) d. Attach the client to a cardiac monitor (2)

1. Which factor puts an older adult at the greatest risk for impaired wound healing after abdominal surgery?

a. Age 75 years b. Age 30 with poorly controlled diabetes.... c. Age 55 years with myocardial infarction d. Age 60 years with peripheral vascular disease

1. A client has a wound on the ankle that is not healing. The nurse should assess the client for which risk factors for delayed wound healing? (Select all that apply)

a. Atrial fibrillation b. Advancing age.... c. Type 2 diabetes mellitus..... d. Hypertension e. Smoking

1. A client with acute renal failure has an increase in the serum potassium level. The nurse should monitor the client for:

a. Cardiac arrest.... b. Pulmonary edema c. Circulatory collapse d. Hemorrhage Hyperkalemia puts the client at risk for cardiac arrhythmias and cardiac arrest, so she should monitor the client and be prepared to initiate CPR if necessary.

1. The nurse should assess which clients for risk for falling? (Select all that apply)

a. Client who is 45 years old, in hospice with terminal cancer, and receiving morphine every 2 hours b. Client who is 70 years of age, hospitalized for lung biopsy, and receiving no medications ( WRONG) c. Client who is 62 years of age, recovering from breast biopsy in outpatient surgery, and has a fear of falling d. Client who is 80 years of age and in a locked facility for clients with cognitive impairment e. Client who is 75 years of age and recovering at home from hip replacement surgery.

1. A HCP prescribes a lengthy x-ray examination for a client with osteoarthritis. Which action by the nurse would demonstrate client advocacy?

a. Contact the x-ray department, and ask the technician if the lengthy session can be divided into shorter sessions..... b. Contact the HCP to determine if an alternative examination could be scheduled c. Request a prescription for acetaminophen prior to the examination d. Request padding for the hard x-ray table

1. At what time of day should the nurse encourage a client with Parkinson's disease to schedule the most demanding physical activities to minimize the effects of hypokinesia?

a. Early in the morning when the client's energy level is high b. To coincide with the peak action of drug therapy.... c. Immediately after a rest period d. When family members will be available

1. The client asks the nurse, "Is it really possible to live a normal life with an ileostomy?" Which action by the nurse would be the most effective to address this question?

a. Have the client talk with a member of the clergy about these concerns b. Tell the client to worry about those concerns after surgery c. Arrange for a person with an ostomy to visit the client preoperatively.... d. Notify the surgeon of the client's question

1. The nurse empties a Jackson-Pratt drainage bulb. Which nursing action ensures correct functioning of the drain?

a. Irrigating it with normal saline b. Connecting it to low intermittent suction c. Compressing it and then plugging it to establish suction.... d. Connecting it to a drainage bag and clamping it off

1. A nurse develops a teaching plan for a client newly diagnosed with Parkinson's disease. Which topic is most important to include in the plan?

a. Maintaining a balanced nutritional diet b. Enhancing the immune system c. Maintaining a safe environment..... d. Engaging in diversional activity The primary focus is maintaining a safe environment because the client with Parkinson's disease usually has a propulsive gait, characterized by a tendency to take increasingly quicker steps while walking, which commonly causes falls or trouble stopping.

1. Which nursing intervention will be most effective when caring for a client who is experiencing powerlessness?

a. Make certain that all staff members focus only on the client's capabilities b. Encourage family members to become more responsible for the client's care c. Request a referral to a psychologist d. Include the client in decision making whenever possible.....

1. The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished DTRs. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia?

a. Muscle twitches b. Decreased urinary output c. Hyperactive bowel sounds..... d. Increased urine specific gravity

1. The nurse is teaching a client who has iron deficiency anemia about foods she should include in her diet. The nurse determines that the client understands the dietary modifications if she selects which items from her menu?

a. Nuts and milk b. Coffee and tea c. Cooked rolled oats and fish d. Oranges and dark green leafy vegetables.....

1. What observation should the nurse instruct the client with an ileostomy to report immediately?

a. Passage of liquid stool from the stoma b. Occasional presence of undigested food in the effluent c. Absence of drainage from the ileostomy for 6 or more hours..... d. Temperature of 99.8*F

1. When changing a wet-to-dry dressing covering a surgical wound, what should the nurse do?

a. Place a dry dressing in the wound b. Use an aqueous solution of aluminum acetate to wet the dressing c. Pack the wet dressing tightly into the wound d. Cover the wet packing with a dry sterile dressing.....

1. Immediately after having surgery to create an ileostomy, which goal has the highest priority?

a. Providing relief from constipation b. Assisting the client with self-care activities c. Maintaining fluid and electrolyte balance...... d. Minimizing odor formation

1. After teaching the client with rheumatoid arthritis about measures to conserve energy in activities of daily living involving the small joints, which activity observed by the nurse indicates the need for additional teaching?

a. Pushing with palms when rising from a chair b. Holding packages close to the body c. Sliding objects d. Carrying a laundry basket with clinched fingers and fists.....

1. The nurse has just assisted a client back to bed after a fall. The nurse and HCP have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next?

a. Reassess the client..... b. Conduct a staff meeting to describe the fall c. Document in the nurse's notes that and incident report was completed d. Contact the nursing supervisor to update information regarding the fall

1. The nurse finds an unlicensed assistive personnel massaging the reddened bony prominences of a client on bed rest. The nurse should:

a. Reinforce the UAP's use of this intervention over bony prominences b. Explain that massage is effective because it improves blood flow to the area c. Inform the UAP that massage is even more effective when combined with lotion during the massage d. Instruct the UAP that massage is contraindicated because it decreases blood flow to the area.....

1. What is a priority to include in the plan of care a client with Alzheimer's disease who is experiencing difficulty processing and completing complex tasks?

a. Repeating the directions until the client follows them b. Asking the client to do one step of the task at a time.... c. Demonstrating for the client how to do the task d. Maintaining routine and structure for the client

1. Which characteristic displayed by the wife of a 36 year old man with pancreatic cancer suggests that she may be at risk for negative bereavement outcomes?

a. She is preparing for her husband's death b. She has a high socioeconomic status c. She has strong family support d. She blames herself for her husband's cancer.....

1. The client is receiving TPN solution. The nurse should assess a client's ability to metabolize the TPN solution adequately by monitoring the client for which sign?

a. Tachycardia b. Hypertension c. Elevated blood urea nitrogen concentration d. Hyperglycemia....

1. Which change in the integumentary system is associated with normal aging?

a. The outer layer of skin is replaced with new cells every 3 days b. Subcutaneous fat and extracellular water decrease.... c. The dermis becomes highly vascular and assists in the regulation of body temperature d. Collagen becomes elastic and strong

1. The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?

a. Twitching.... b. Hypoactive bowel sounds c. Negative Trousseau's sign d. Hypoactive DTRs Signs of hypocalcemia include paresthesia followed by numbness, hyperactive DTRs and positive Trousseau's or Chvostek's sign. Other signs: increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety.