EAQs Basics of Nursing Practice; Physiological Aspects of Care

Among the following clients, which is at the highest risk for hepatitis infection?

A gay man

Place each step of the nursing process in the order that it should be used

1.Obtain client's nursing history. 2.Determine client's nursing needs. 3.Establish goals for care. 4.Develop a plan of care. 5.Implement nursing interventions

A client has an anaphylactic reaction after receiving intravenous penicillin. What does the nurse conclude is the cause of this reaction?

Antibodies to penicillin developed after a previous exposure.

A female client explains that she sleeps until noon every day and takes frequent naps during the rest of the day. What should the nurse do initially?

Arrange a referral for the client for a thorough medical evaluation

Which part of the nursing process is documented in discharge and transfer forms?

Assessment

A nurse identifies that a client's IV site is warm, red, and tender. What does the nurse conclude is the most likely cause of this finding?

Chemical irritation to the tissues

Which process involves transferring responsibility to multiple players, usually with varying degrees of education and experience, while retaining the ultimate accountability for providing the client care?

Delegation

A health-care agency plans to provide incentives to a primary healthcare provider who is providing home health care. Which act is being followed by the health-care agency in this situation?

Tax Equity and Fiscal Responsibility Act

While caring for a client with asthma, the delegator assigns the client to a registered nurse (RN) and to a licensed practical nurse (LPN). Which component of delegation is transferable to the RN? Select all that apply.

Authority Responsibility Accountability

For which situations would total client care be an appropriate delivery system? Select all that apply

Client with an endotracheal tube for pulmonary sepsis Client recovering from cardiovascular bypass graft surgery Client recovering from the placement of a cerebrospinal fluid shunt

Which is a requirement for admission to a hospice care facility?

Clients informed consent

The registered nurse is teaching the student nurse about the concepts of delegation. Which response given by the student nurse indicates the need for further teaching?

Delegation is the transfer of accountability while retaining responsibility

A nurse documents the blood glucose levels before and after the administration of insulin and finds improvement in the client's condition. Which format of SOAPER describes this documentation?

Evaluation

Which action of the nurse ensures safety during rectal temperature measurement?

Holding onto the thermometer throughout the procedure

Which statements are true regarding narrative charting? Select all that apply

It includes the data about the basic client need or problem It is used for computerized and noncomputerized nurse's notes

A client with hemiplegia is staring blankly at the wall and reports feeling like half a person. What is the most appropriate initial nursing action?

Offer to spend more time with the client.

A client asks about the purpose of a pulse oximeter. The nurse explains that it is used to measure what?

Percentage of hemoglobin-carrying oxygen

An agency is governed by a hospital board of directors, provides limited community health care, and receives fees from all sources. What type of agency might this be? Select all that apply.

Private for-profit institution-based Private nonprofit institution-based A hospital-based home health agency is governed by a hospital board of directors. This agency receives fees from all sources. A hospital-based agency is considered private and institution-based; it may be a profit-based or nonprofit-based agency. An official health agency would be a public nonprofit freestanding organization. A proprietary health agency would be considered private for-profit freestanding. A private not-for-profit agency would be classified as private nonprofit freestanding.

A nurse leader finds a post-operative client in a semi-conscious state due to the after effects of anesthesia. The client has impaired psychomotor functions. Which need of the client would the nurse leader prioritize according to Maslow's subcategories of human needs?

Safety and Security

A client with Addison's disease is receiving cortisone therapy. The nurse expects what clinical indicators if the client abruptly stops the medication? Select all that apply.

Tachypnea Hypotension

During a review in the health-care setting, the manager communicates with employees and understands that the style of leadership is democratic. What made the manager interpret this way?

The leader stresses the self-worth of every individual.

A nurse is educating a patient about Maslow's hierarchy of needs by citing examples. Which examples mentioned by the nurse belong to the third level of needs? Select all that apply.

(Third level of needs: Love and Belonging) "A client is depressed because his/her spouse has passed away." "A client wants to reconnect with old friends after being diagnosed with cancer." "A client never goes to family gatherings because he/she is not accepted by family members."

A client with Crohn disease who weighs 155 lb (70.3 kg) is to receive an infusion of infliximab 5 mg/kg. What is the correct dose in milligrams that the client should receive? Record your answer using a whole number. ___ mg

352 (round up)

A nurse suspects that a client has poison ivy. Assessment findings reveal vesicles on the arms and legs. What definition best describes a vesicle?

A lesion filled with serous fluid.

After a train accident, severely injured clients are sent in large masses to an emergency department. A nurse leader prepares the staff for the care of the trauma victims. Which type of leadership would be most beneficial in this situation?

Autocratic Leadership.

While caring for a client with schizophrenia, a nurse understands that psychotherapy is against the client's religious beliefs. To which religious community does the client likely belong?

Christian Science

A nurse is caring for a client who is having diarrhea. To prevent an adverse outcome, the nurse should most closely monitor what patient data or assessment finding?

Fluid and electrolyte balance

A client has been diagnosed as "brain dead". What does the nurse understand that this means?

The client has no cortical functioning with some reflex breathing.

After administration of the MMR vaccine, a child develops pain, fever, and soreness. The primary healthcare provider asks the nurse to assess the child for joint swelling and to send a blood sample for a blood platelet count. Which is the most appropriate reason behind these interventions?

To assess the risk of thrombocytopenia

Which statement is true regarding factors that affect body temperature?

Women generally have greater variations in body temperature than men.

A nurse is caring for a client who has a poor understanding of weight reduction strategies. The nurse instructs the client to follow a healthy diet regularly because crash dieting can lead to serious health issues. Which of these reactions might the nurse expect if the client is in the precontemplation stage? Select all that apply.

"As far as I know, having a thin body means that I'm healthy." "Who says that I don't eat properly? I'm just skipping my breakfast. "I don't care about following the diet plan; I just want to lose weight as soon as possible."

A licensed practical nurse cares for an Orthodox Jewish woman who gave birth to a boy 5 days ago. The nurse is aware that the baby is premature and having respiratory difficulties and that the parents are very worried. Which nursing actions demonstrate an awareness of appropriate cultural norms in this situation? Select all that apply.

"Asking the client, "Why don't you have some cheese now, and later on we'll get you some grilled meat." Telling the client's husband, who is standing by her bed, "Why don't you come sit here while I help her sit up in bed?"

A nurse caring for a pregnant client prioritizes nursing actions on the basis of Maslow's hierarchy of needs. Which statement of the client does the nurse consider to be a self-esteem need?

"I deserve ill treatment from my husband as I'm incapable of doing even simple things perfectly."

After observing a client waiting for food, the nurse leader instructs the nurse to make arrangements for food. Which statement used by the nurse to the client appropriately makes his or her positive intent explicit?

"I want to make you comfortable, here's your food."