EAQ's: Fundamentals of Nursing

Which intrinsic factor is associated with the fall of an older adult? 1- Wet floors 2- Poor lighting 3- Deconditioning 4- Inappropriate footwear

3- Deconditioning

When caring for a client with varicella and disseminated herpes zoster, the nurse should implement which types of precautions? Select all that apply. Airborne Contact Droplet Hazardous wastes Standard

Airborne Contact Standard

A client has been diagnosed as brain dead. The nurse understands that this means that the client has what? No spontaneous reflexes Shallow and slow breathing No cortical functioning with some reflex breathing Deep tendon reflexes only and no independent breathing

No cortical functioning with some reflex breathing

The nurse is asking a client with arthritis questions in order to collect information. Which questions asked by the nurse are closed-ended questions? Select all that apply. "Are you having pain?" "Tell me how your pain has been." "Describe how your husband is helping you at home." "Do you think the medication is helping you to get pain relief?" "Give me an example of a method which helps you to get pain relief at home."

"Are you having pain?" "Do you think the medication is helping you to get pain relief?"

While caring for a client with a Hemovac portable wound drainage system, the nurse observes that the collection container is half full. The nurse empties the container. What is the next nursing intervention? Encircle the drainage on the dressing. Irrigate the suction tube with sterile saline. Clean the drainage port with an alcohol wipe. Compress the container before closing the port.

Compress the container before closing the port.

Which findings in the older client are associated with a urinary tract infection (UTI)? Select all that apply. Fever Urgency Confusion Incontinence Slight rise in temperature

Confusion Incontinence Slight rise in temperature

While a nurse is teaching a client with diabetes about food choices, the client states, "I do not like broccoli." Which food should the nurse suggest to substitute for broccoli? Peas Corn Green beans Mashed potato

Green beans

Which subdimension would form a part for the caring process "doing for" according to the Swanson's theory of caring? Select all that apply. Focusing Protecting Comforting Seeking cues Generating alternatives

Protecting Comforting

Which standards would the nurse explain are important for critical thinking? Select all that apply. Specific Fairness Relevant Confidence Independence

Specific & Relevant

To prevent skin breakdown on the scalp of an infant with hydrocephalus, how should the nurse position the infant? On either side and flat Supine and Trendelenburg Prone, with the legs elevated about 30 degrees Supine, with the head elevated about 45 degrees

Supine, with the head elevated about 45 degrees

Which hospital department plays a primary role in disaster preparedness? 1- Medical department 2- Surgical department 3- Emergency department 4- Mental health department

3- Emergency department

To prevent thrombophlebitis in the immediate postoperative period, which action is most important for a nurse to include in the client's plan of care? 1- Increase fluid intake. 2- Restrict fluids. 3- Encourage early mobility. 4- Elevate the knee gatch of the bed.

3- Encourage early mobility.

A client has a platelet count of 49,000/mL (40 × 10 9/L). The nurse should instruct the client to avoid which activity? Ambulation Blowing the nose Visiting with children The semi-Fowler position

Blowing the nose

A registered nurse is caring for a client who is on isolation precautions. Which tasks can be safely assigned to the nursing assistive personnel? Select all that apply. Assessing vital signs Administering injections Assessing wound drainage Bringing equipment to the client's room Transporting the client to a diagnostic test

Bringing equipment to the client's room Transporting the client to a diagnostic test

An older client is apprehensive about being hospitalized. The nurse realizes that one of the stresses of hospitalization is the unfamiliarity of the environment and activity. How can the nurse best limit the client's stress? Use the client's first name. Visit with the client frequently. Explain what the client can expect. Listen to what the client has to say.

Explain what the client can expect.

A registered nurse advises a nursing student to value learning for learning's sake. Which concept of critical-thinking behavior is the registered nurse referring to? Analyticity Systematicity Inquisitiveness Self-confidence

Inquisitiveness

The way individuals cope with an unexpected hospitalization depends on many factors. However, what is the one that is most significant? Cognitive age Past coping styles Financial resources General physical health

Past coping styles

The nursing team is providing care for a client. The team leader develops client care plans and coordinates care among the team members. Which member of the team acts as a team leader? Charge nurse Registered nurse Licensed practical nurse Unlicensed assistive personnel

Registered nurse

A mother who is visiting the pediatric clinic with her 10-month-old son tells the nurse how pleased she is with her chubby infant. She exclaims, "Look how much weight he's gained even though he drinks only orange juice! He won't drink any milk!" What is best response by the nurse? "He's a little overweight." "Let's talk about his nutrition." "Is he getting an iron supplement?" "Why is he only drinking orange juice?"

"Let's talk about his nutrition."

A teenager is being discharged with a cast. What should the nurse recommend if the client experiences pruritus around the cast edges? "Scratch the itchy area gently." "Put an ice pack on the affected area." "Sprinkle a layer of powder around the itchy spots." "Ask your doctor for a prescription for an antihistamine."

"Put an ice pack on the affected area."

An infant is to be discharged after surgery for pyloric stenosis. What instructions should the nurse give the parents? "Offer the baby creamy cereal at each feeding, and follow it with a regular formula." "Hold the baby while continuing to feed a regular formula slowly and burp frequently." "Allow the baby to drink about 1 oz (30 mL) of a regular formula per hour for a week, and progress slowly to larger amounts." "Place the baby on the right side in the crib during feedings with regular formula, and minimize handling for 2 hours after feeding."

"Hold the baby while continuing to feed a regular formula slowly and burp frequently."

The registered nurse is teaching a nursing student about caring for a client who has difficulty speaking English. Which statement made by the nursing student would cause communication problems with the client? "I will give the client a call bell." "I will involve the client's family members as interpreters." "I will provide a dictionary to the client if the client can read." "I will use boards and pictures to communication with the client."

"I will involve the client's family members as interpreters."

A client with a disturbed state of mind is under observation. Which statement made by the nurse indicates that the client is suffering from dementia? Select all that apply. "The client is very depressed." "The client is not able to make decisions." "The client always tells about his/her failures." "The client is not able to perform purposeful work." "The client has a completely disturbed sleep/wake cycle."

"The client is not able to make decisions." "The client is not able to perform purposeful work."

What are the goals of care when working with families according to the family health system? Select all that apply. 1- To improve family health or well-being 2- To help the family prepare for later transitions 3- To assist in family management of illness conditions 4- To promote positive family behaviors to achieve essential tasks 5- To achieve health outcomes related to the family's areas of concern

1, 3, & 5 To improve family health or well-being To assist in family management of illness conditions To achieve health outcomes related to the family's areas of concern

A nurse in the ambulatory preoperative unit identifies that a client is more anxious than most clients. What is the nurse's best intervention? 1- Attempt to identify the client's concerns. 2- Reassure the client that the surgery is routine. 3- Report the client's anxiety to the healthcare provider. 4- Provide privacy by pulling the curtain around the client.

1- Attempt to identify the client's concerns.

A client with dementia who feels highly anxious and confused believes that the current day is actually different than what it is. Which statement made by the nurse is an example of validation therapy? 1-"No, try to be in your sense of reality." 2- "Yes, today is the day that you just mentioned." 3- "You should try improving your awareness level." 4- "Try to recall your past memories associated with the day."

2- "Yes, today is the day that you just mentioned."

A client admitted to the hospital with a diagnosis of malabsorption syndrome exhibits signs of tetany. The nurse concludes that the tetany was precipitated by the inadequate absorption of which electrolyte? 1- Sodium 2- Calcium 3- Potassium 4- Phosphorus

2- Calcium

Which interventions should the nurse perform when caring for an actively dying client? Select all that apply. 1- Admit the client to hospice care. 2- Draw blood for laboratory tests. 3- Reassure the client and family. 4- Avoid disturbances to the client. 5- Manage the client's symptoms.

3 & 5 3- Reassure the client and family. 5- Manage the client's symptoms.

In the clinical setting, which clients exhibit affiliative motivation? Select all that apply. A client who follows a low-fat diet due to the fear of having a heart attack An obese teenager who follows dietary restrictions to fit in with a peer group A client who becomes a vegetarian, loses weight, and continues with the change A client who complies with taking their medication to please the client's spouse A young person who performs aerobic exercise and also teaches others to exercise

An obese teenager who follows dietary restrictions to fit in with a peer group A client who complies with taking their medication to please the client's spouse

Which risks would the nurse state may be associated with adults who work on or around automobiles? Select all that apply. Infertility Asbestosis Dermatitis Skin cancer Nasopharyngeal cancer

Asbestosis & Dermatitis

The nurse is caring for a client who underwent a rhinoplasty surgical procedure 5 hours ago. After administering pain medication, the nurse notes the client is swallowing frequently. The nurse understands that the cause of frequent swallowing is most likely from what? A normal response to the analgesic Oral dryness caused by nasal packing An adverse reaction to anesthesia Bleeding posterior to the nasal packing

Bleeding posterior to the nasal packing

While measuring the rectal temperature, the nurse inserts the thermometer probe 2.5 to 3.5 cm into the anus in the direction of the umbilicus. What would be the rationale behind this? Provide comfort to the client Minimize trauma to rectal mucosa Reduce transmission of microorganisms Ensure adequate exposure to the blood vessels

Ensure adequate exposure to the blood vessels

The nurse is assisting with the end-of-life care of an older adult. Which activity is performed when the nurse views family as context? Assess the resources available to the family Meet the client's family's comfort and nutritional needs Meet the client's comfort, hygiene and nutritional needs Determine the family's need for rest and their stage of coping

Meet the client's comfort, hygiene and nutritional needs

The registered nurse asks a client to rate his or her pain on a scale from 0 to 10, then instructs the nursing student to perform a physical assessment. Which assessments performed by the nursing student would be appropriate? Select all that apply. Palpating for tenderness Observing nonverbal cues Inspecting any areas of discomfort Noticing if the pain localized or radiated Noticing if the client gives nonverbal signs of pain

Palpating for tenderness Inspecting any areas of discomfort

A client has a "prayer cloth" pinned to the hospital gown. The cloth is soiled from being touched frequently. What should the nurse do when changing the client's gown? Make a new prayer cloth. Discard the soiled prayer cloth. Pin the prayer cloth to the clean gown. Wash the prayer cloth with a mild detergent.

Pin the prayer cloth to the clean gown.

Before administering a nasogastric feeding to a preterm infant, the nurse aspirates a small amount of residual fluid from the stomach. What is the nurse's next action? Returning the aspirate and withholding the feeding Discarding the aspirate and administering the full feeding Returning the aspirate and subtracting the amount of the aspirate from the feeding Discarding the aspirate and adding an equal amount of normal saline solution to the feeding

Returning the aspirate and subtracting the amount of the aspirate from the feeding

A recently hospitalized client with multiple sclerosis is concerned about generalized weakness and fluctuating physical status. What is the priority nursing intervention for this client? Encourage bed rest. Space activities throughout the day. Teach the limitations imposed by the disease. Have one of the client's relatives stay at the bedside.

Space activities throughout the day.

During the beginning phase of a therapeutic relationship, why is a clear understanding of participants' roles important? The client should understand what will be discussed. The client will know that the nurse is trying to be helpful. The client needs to know what to expect from the relationship. The client will be able to be prepared for termination of the relationship.

The client needs to know what to expect from the relationship.

A client is hospitalized because of severe depression. The client refuses to eat, stays in bed most of the time, does not talk with family members, and will not leave the room. The nurse attempts to initiate a conversation by asking questions but receives no answers. Finally the nurse tells the client that if there is no response, the nurse will leave and the client will remain alone. How should the nurse's behavior be interpreted? A system of rewards and punishment is being used to motivate the client. Leaving the client alone allows time for the nurse to think of other strategies. This behavior indicates the client's desire for solitude that the nurse is respecting. This threat is considered assault, and the nurse should not have reacted in this manner.

This threat is considered assault, and the nurse should not have reacted in this manner.

What is an example of the critical thinking attitude of independent thinking in nursing practice? To refer to a policy and procedure manual to review steps of a skill To talk with other nurses to share ideas about nursing interventions To recognize when one requires more information for making a decision To explore and learn more about the client for making appropriate clinical judgments

To talk with other nurses to share ideas about nursing interventions

How should a nurse intervene when a confused and anxious client voids on the floor in the sitting room of the mental health unit? Make the client mop the floor. Restrict the client's fluids for the rest of the day. Toilet the client more frequently with supervision. Withhold the client's privileges each time the client voids on the floor.

Toilet the client more frequently with supervision.

A client who is dying jokes about the situation even though the client is becoming sicker and weaker. Which is the most therapeutic response by the nurse? 1- "Why are you always laughing?" 2- "Your laughter is a cover for your fear." 3- "Does it help to joke about your illness?" 4- "The person who laughs on the outside cries on the inside."

3- "Does it help to joke about your illness?"

A preschool child is found to have atopic dermatitis. The nurse emphasizes that the child should be discouraged from scratching. The child's mother asks why scratching should be prevented. What is the nurse's response? 1- "Scratching causes lesions to become more contagious." 2- "Scratching spreads dermatitis to other areas of the body." 3- "Scratching results in skin breaks that can lead to infection." 4- "Scratching produces changes that are precursors to skin cancer."

3- "Scratching results in skin breaks that can lead to infection."

What should the nurse encourage the parents of a child with plumbism (lead poisoning) to do? 1- Discourage the child's pica by providing nutritious snacks. 2- Move the family away from areas that are next to gas stations. 3- Assess the family's home environment for lead sources and have them removed. 4- Have the child take repeat x-rays of the wrist and forearm for signs of a lead line.

3- Assess the family's home environment for lead sources and have them removed.

During the first well-baby visit after discharge from the hospital, the mother informs the nurse that her baby has difficulty sucking and swallowing and tires easily. What should the nurse consider when assessing this infant? 1- Newborns tend to tire easily, especially when feeding. 2- Decreased sucking is insignificant in the absence of cyanosis. 3- Difficulty when feeding may be an early indication of a heart defect. 4- Some infants retain mucus for several days that may interfere with feeding.

3- Difficulty when feeding may be an early indication of a heart defect.

A mother of a seven-month-old infant reports that her baby still cannot sit without support. Upon asking further questions, the nurse realizes that the child's gross-motor skills are not properly developed. Which question did the nurse most likely ask the mother? Can your child hold on to furniture? Can your child show hand preference? Does your child move on his or her hands and knees? Can your child place objects in containers?

Can your child hold on to furniture?

A registered nurse is teaching a nursing student about how to safely use a urinary catheter. Which statement made by the nursing student indicates ineffective learning? "I will avoid the pooling of urine in the tubing." "I will avoid prolonged clamping of the tubing." "I will avoid draining urine from the tubing before ambulation." "I will avoid raising the drainage tube above the level of the bladder."

"I will avoid draining urine from the tubing before ambulation."

According to Kohlberg's development of moral reasoning, at which phase of life would a child develop premoral orientation? Preschool Adolescence Middle childhood Early childhood/toddler

Preschool

An older adult who is in acute care has a risk of skin breakdown. Which interventions are beneficial to the client? Select all that apply. Providing meticulous skin care Reducing shear forces and friction Providing beverages and snacks frequently Using a support surface base all the time Avoiding pressure with proper positioning

Providing meticulous skin care Reducing shear forces and friction Avoiding pressure with proper positioning

A nurse is teaching a school-aged child with juvenile idiopathic arthritis (JIA) activities to prevent the loss of joint function. What should the nurse caution the child to avoid? Bicycle riding Walking to school Isometric exercises Sedentary activities

Sedentary activities

The nurse plans care for a client who has anxiety related to uncertainty over the course of recovery. Which action of the client would indicate that the desired goal is achieved? The client discusses the surgical outcomes with the surgeon. The client shares concerns with the spouse before discharge. The client describes the effects surgery will have on recovery. The client expresses acceptance of health status by the day of discharge.

The client expresses acceptance of health status by the day of discharge.

A client has paraplegia as a result of a motorcycle accident. What is the reason the nursing care plan should include turning the client every 1 to 2 hours? 1- Maintain comfort 2- Prevent pressure ulcers 3- Prevent flexion contractures of the extremities 4- Improve venous circulation in the lower extremities

2- Prevent pressure ulcers

The nurse is using non-verbal active listening skills during a clinical therapeutic encounter with a client. Which non-verbal action best conveys engagement in this client interaction? Sitting with a relaxed posture Leaning toward the client Making eye contact Facing the client

Leaning toward the client

What does the professional nurse consider to be the center of decision-making when providing client care? 1- Ethics of care 2- Nursing skills 3- Analytical skills 4- Research based practice

1- Ethics of care

A client is receiving hypertonic tube feedings. What should the nurse consider to be the main reason this client may experience diarrhea? Increased fiber intake Bacterial contamination Inappropriate positioning High osmolarity of the feedings

High osmolarity of the feedings

What are the advantages of the team nursing model of providing nursing care? Select all that apply. The nursing care conferences help to solve client problems. The client satisfaction is highest compared to other models. The model provides a high level of autonomy for the team leader. The registered nurses are responsible for planning care for each client. The model facilitates a high level of collaboration between team members.

The nursing care conferences help to solve client problems. The model provides a high level of autonomy for the team leader. The model facilitates a high level of collaboration between team members.

A nurse is providing immediate postoperative care to a client who had a lung resection for a malignancy. The client has a closed chest tube drainage system connected to suction. Which assessment finding requires additional evaluation by the nurse? A column of water 20 cm high in the suction control chamber 75 mL of bright red blood in the drainage collection chamber An intact occlusive dressing at the insertion site Constant bubbling in the water seal chamber

Constant bubbling in the water seal chamber

A nurse in the emergency department is assessing a young child with a head injury. The child is accompanied by a parent. Which observation should prompt the nurse to assess the child for abuse? The child has Mongolian spots on the back. The child belongs to a single-parent family. The child has received care for injuries twice earlier. The child and parent narrate the same story about the injury.

The child has received care for injuries twice earlier.

Which caring process is defined as "facilitating the other's passage through life transitions and unfamiliar events" according to Swanson's theory of caring? 1- Knowing 2- Enabling 3- Doing for 4- Being with

2- Enabling

When caring for a client with venous insufficiency, the nurse would implement which nursing measure? 1- Apply abdominal girdle as needed. 2- Remove compression stockings for client ambulation. 3- Elevate the client's legs above heart level. 4- Keep the upper extremities elevated.

3- Elevate the client's legs above heart level.

Which developmental changes should be evaluated in girls around 12 years of age? 1- Motor skills 2- Visual acuity 3- Skeletal growth 4- Hormonal changes

3- Skeletal growth

After abdominal surgery a client reports pain. What action should the nurse take first? 1- Reposition the client. 2- Obtain the client's vital signs. 3- Administer the prescribed analgesic. 4- Determine the characteristics of the pain.

4- Determine the characteristics of the pain.

The nurse is caring for a client with Alzheimer disease who exhibits behaviors associated with hyperorality. To meet the client's need for a safe milieu, what instructions will the nurse give the staff to monitor the client? 1- At meals to help prevent choking 2- For the presence of mouth ulcers 3- To prevent injury caused by hot foods 4- For attempts at eating inedible objects

4- For attempts at eating inedible objects

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

While communicating with a client, the nurse determines that the client has realized the harmful effects of alcohol consumption and plans to stop drinking within 6 months. To what stage of Transtheoretical Model of Change does the nurse correlate the client's behavior? Action Preparation Maintenance Contemplation

Contemplation

A client is receiving an intravenous infusion of 5% dextrose in water. The client loses weight and develops a negative nitrogen balance. The nurse concludes that what likely contributed to this client's weight loss? Excessive carbohydrate intake Lack of protein supplementation Insufficient intake of water-soluble vitamins Increased concentration of electrolytes in cells

Increased concentration of electrolytes in cells

After gastric surgery a client has a nasogastric tube in place. What should the nurse do when caring for this client? Monitor for signs of electrolyte imbalance. Change the tube at least once every 48 hours. Connect the nasogastric tube to high continuous suction. Assess placement by injecting 10 mL of water into the tube.

Monitor for signs of electrolyte imbalance.

The nurse is caring for a client who got discharged from the hospital. The nurse finds that the client is having difficulty in determining which medications to take. What would be the best nursing intervention in this situation? The nurse fills and labels the medication bottles. The nurse advises the caregiver to support the client in taking medication. The nurse recommends the client's pharmacy to re-label the medication in large letters. The nurse shows the client examples of pill organizers that will help the client to sort the medication.

The nurse recommends the client's pharmacy to re-label the medication in large letters.

A nurse is caring for a client who has paraplegia as a result of a spinal cord injury. Which rehabilitation plan will be most effective for this client? Arrangements will be made by the client and the client's family. The plan is formulated and implemented early in the client's care. The rehabilitation is minimal and short term, because the client will return to former activities. Arrangements will be made for long-term care, because the client is no longer capable of self-care.

The plan is formulated and implemented early in the client's care.

The registered nurse teaches a nursing student about leadership skills for prioritizing the need of the client depending on the situation. Which statement is an example of an intermediate priority need? "The teachings of home self-care." "A psychological episode of an anxiety attack." "A physiological episode of an obstructed airway." "The measures required to decrease postoperative complications."

"The measures required to decrease postoperative complications."

While receiving a preoperative enema, a client starts to cry and says, "I'm sorry you have to do this messy thing for me." What is the nurse's best response? "I don't mind it." "You seem upset." "This is part of my job." "Nurses get used to this."

"You seem upset."

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 "alternative 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."

What would be the behavioral characteristic of a slow-to-warm up child according to the theory related to temperament? 1- Highly active 2- Irritable and irregular in habits 3- Negative reaction to new stimuli 4- A positive mild-to-moderately intense mood

3- Negative reaction to new stimuli

Non-weight bearing with crutches has been prescribed for a client with a leg injury. The nurse provides teaching before ambulation is begun. To facilitate walking with crutches, what is the most important activity the nurse should teach the client? Sit up in a chair to help strengthen back muscles. Keep the unaffected leg in extension and abduction. Exercise the triceps, finger flexors, and elbow extensors. Use a trapeze frequently to strengthen the biceps muscles.

Exercise the triceps, finger flexors, and elbow extensors.

A client has a right-above-the-knee amputation after trauma sustained in a work-related accident. Upon awakening from surgery, the client states, "What happened to me? I don't remember a thing." What is the nurse's best response? "Tell me what you think happened." "You will remember more as you get better." "You were in a work-related accident this morning." "It was necessary to amputate your leg after the accident."

You were in a work-related accident this morning."

Which theory proposes that older adults experience a shift from a materialistic to cosmic view of the world? 1- Activity theory 2- Continuity theory 3- Disengagement theory 4- Gerotranscendence theory

4- Gerotranscendence theory

The family of an older adult who is aphasic reports to the nurse manager that the primary nurse failed to obtain a signed consent before inserting an indwelling catheter to measure hourly output. What should the nurse manager consider before responding? Procedures for a client's benefit do not require a signed consent. Clients who are aphasic are incapable of signing an informed consent. A separate signed informed consent for routine treatments is unnecessary. A specific intervention without a client's signed consent is an invasion of rights.

A separate signed informed consent for routine treatments is unnecessary.

A hospitalized 10-year-old child is apathetic about eating. What is the best nursing intervention to support the child's nutrition? Asking the parents to visit at mealtimes Having a nursing assistant feed the child Providing diversional activity at mealtimes Eliminating the child's between-meal snacks

Asking the parents to visit at mealtimes

What are the levels of critical thinking in nursing? Select all that apply. Basic Analyze Evaluate Complex Commitment

Basic, Complex, and Commitment

The registered nurse is teaching the nursing student about the realms of family life. Which component does the registered nurse include while teaching about integrity processes? Family rituals Family relationships Family life stressors and daily hassles Family care takings and responsibilities

Family rituals

The nurse is caring for an infant at the healthcare facility. Which nursing intervention fosters the infant's development of trust? Follow the parents' directions while providing care. Ask parents to name objects in the infant's surroundings. Encourage different caregivers to interact with the infant. Encourage caregivers to talk to the infant while providing care.

Follow the parents' directions while providing care.

Which is the first sign that would help the nurse in diagnosing malignant hyperthermia in a client? Abnormal rapid heart rate Abnormal rapid breathing Increased body temperature Increased expired carbon dioxide

Increased expired carbon dioxide

The nurse is assessing a new mother at a healthcare facility. Which symptom does the nurse identify as a risk factor for postpartum blues? Frantic energy Mild irritability Hallucinations Unwillingness to sleep

Mild irritability

A school nurse works with adolescents who recently immigrated to the U.S. and are adjusting to life in the public schools. What characteristics help the nurse differentiate students who are assimilating from students who are acculturating? Students who acculturate shun all aspects of their new culture. Students who assimilate are generally unhappy in their new culture. Students who acculturate tend to be more social in their new culture. Students who assimilate abandon all aspects of their original culture.

Students who assimilate abandon all aspects of their original culture.

Which nursing actions reflect the carative factor of 'promoting and expressing positive and negative feelings' according to the Watson's transpersonal caring? Select all that apply. Supporting and accepting the client's feelings Learning together while educating the client to acquire self-care skills Creating a healing environment at the physical and nonphysical levels Applying the nursing process in systematic, scientific problem-solving decision-making Showing a willingness to take risks in sharing in the relationships when connecting with clients

Supporting and accepting the client's feelings & Showing a willingness to take risks in sharing in the relationships when connecting with clients

While performing cardiac surgery, the cardiologist intentionally induces hypothermia in the client. The nurse understands that the rationale for this intervention is what? To prevent tissue ischemia To enhance anesthetic action To prevent blood loss during surgery To complete the surgery in short time

To prevent tissue ischemia

A nurse is providing care to a client 8 hours after the client had surgery to correct an upper urinary tract obstruction. Which assessment finding should the nurse report to the surgeon? Incisional pain Absent bowel sounds Urine output of 20 mL/hr Serosanguineous drainage on the dressing

Urine output of 20 mL/hr

The home health nurse provides education to a client with cancer of the tongue who will begin gastrostomy feedings at home. Which statement by the client indicates teaching by the nurse is effective? "Before I start the procedure, I will don sterile gloves." "Before I start the procedure, I will obtain my body weight." "Before I start the procedure, I will measure the residual volume." "Before I start the procedure, I will instill one ounce (30 mL) of a carbonated liquid."

"Before I start the procedure, I will measure the residual volume."

Which question asked by the nurse is an example of open-ended questions? "How has your health been?" "Are you feeling any pain now?" "Do you think the medication is helping you?" "How would you rate your pain on a scale from 0 to 10?"

"How has your health been?"

In an interview, the manager is looking for a nurse who excels in analyticity. Which statement made by the nurse would help him or her to get selected for the new project? "I am able to make my own decisions." "I am highly organized and focused in my work." "I am good at using evidence-based knowledge." "I am very passionate about acquiring knowledge."

"I am good at using evidence-based knowledge."

The nurse is assessing a client with arthritis. Which statement made by the client indicates a precipitating factor that is an intellectual standard for critical thinking? "The pain is usually present in my fingers and knees." "I observed swelling and redness near the pain area." "I feel the pain in each and every joint of my hands and legs." "I run for 30 minutes every day; this exercise increases my pain."

"I run for 30 minutes every day; this exercise increases my pain." A precipitating factor is an activity or factor that worsens the symptoms.

Which physiologic changes may occur during the first trimester of pregnancy? Select all that apply. 1- Fatigue 2- Increased libido 3- Morning sickness 4- Breast enlargement 5- Braxton Hicks contractions

1, 3, &4 Fatigue Morning Sickness Breast Enlargement

For which clinical indication should a nurse observe a child in whom autism is suspected? 1- Lack of eye contact 2- Crying for attention 3- Catatonia-like rigidity 4- Engaging in parallel play

1- Lack of eye contact

What type of functional health pattern would the nurse explain describes values and goals? 1- Value-belief pattern 2- Role-relationship pattern 3- Self-perception-self-concept pattern 4- Health perception-health management pattern

1- Value-belief pattern

A newly hired nurse during orientation is approached by a surveyor from the department of health. The surveyor asks the nurse about the best way to prevent the spread of infection. What is the most appropriate nursing response? 1- "Let me get my preceptor." 2- "Wash your hands before and after any client care." 3- "Clean all instruments and work surfaces with an approved disinfectant." 4- "Ensure proper disposal of all items contaminated with blood or body fluids."

2- "Wash your hands before and after any client care."

A 13-year-old is found to have idiopathic scoliosis. She is upset about the treatment regimen and is worried about being different from her friends. What should the nurse do to help the child maintain a positive self-image during treatment? 1- Remind her how crooked her back will be if she refuses treatment. 2- Help her investigate appropriate clothing to enhance her appearance. 3- Disregard her negative characteristics and focus on her positive attributes. 4- Refer her for psychological counseling until the treatment program is completed.

2- Help her investigate appropriate clothing to enhance her appearance.

The nurse has provided instructions about back safety to a client. Which client statement indicates understanding of the instructions? 1- "I should carry objects about 18 inches from my body." 2- "I should sleep on my stomach with a firm mattress." 3- "I should carry objects close to my body." 4- "I should pull rather than push when moving heavy objects."

3- "I should carry objects close to my body."

A client is being admitted to a medical unit with a diagnosis of pulmonary tuberculosis. The nurse should assign the client to which type of room? 1- Private room 2- Semiprivate room 3- Room with windows that can be opened 4- Negative-airflow room

4- Negative-airflow room

The nurse receives information about a client through another nurse. The nurse then finds that information has some missing facts. Which critical thinking attitude would the nurse use to clarify the information after talking to the client directly? 1- Fairness 2- Humility 3- Discipline 4- Perseverance

4- Perseverance

A client is admitted to the hospital with a diagnosis of acute Guillain-Barré syndrome. Which assessment is priority? 1- Urinary output 2- Sensation to touch 3- Neurologic status 4- Respiratory exchange

4- Respiratory exchange

The nurse receives an order to prepare a solution for administering a cleansing enema for a 15-year-old client. What is the volume of solution that the nurse should prepare? 150 to 250 mL 250 to 350 mL 300 to 500 mL 500 to 750 mL

500 to 750 mL

Which example best demonstrates humility in a critical thinker? A nurse questions the occurrence of pneumonia in a client who has a history of smoking. A nurse finds a client in pain and asks specific and detailed questions about the pain in order to provide pain relief. A nurse in a surgical scrub touches a contaminated surface and performs the whole process of surgical scrub again. A nurse accepts his or her lack of knowledge regarding stem cell transplantation and seeks opportunities for learning.

A nurse finds a client in pain and asks specific and detailed questions about the pain in order to provide pain relief.

After an amputation of a limb, a client begins to experience extreme discomfort in the area where the limb once was. What is the nurse's greatest concern at this time? Addressing the pain Reversing feelings of hopelessness Promoting mobility in the residual limb Acknowledging the grieving for the lost limb

Addressing the pain

The registered nurse is teaching a student nurse about making assumptions with an open mind when looking at information about a client. Which critical thinking skill is being referred to? Analysis Inference Evaluation Interpretation

Analysis

A client is placed on a restricted diet. What is the best communication technique for the nurse to use when beginning to teach the client about the diet? Asking about what type of foods the client usually eats Telling the client that the diet must be followed exactly as written Telling the client that the intake of foods on the list must be limited Asking about what the client knows about the diet that was prescribed

Asking about what the client knows about the diet that was prescribed

What interventions should the nurse follow when giving health education to an elderly client? Select all that apply. Assess the client for pain before teaching. Take down notes while talking to the client. Ensure the client is not preoccupied or anxious. Teach one concept at a time according to the client's interest. Teach a family caregiver if the client does not respond quickly.

Assess the client for pain before teaching. Ensure the client is not preoccupied or anxious. Teach one concept at a time according to the client's interest.

Elbow restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. What is most important for the nurse to do? Have the prescription renewed every 48 hours. Assess the client's condition per hospital protocol. Provide range of motion to the client's elbows every shift. Document output from the tube and catheter every two hours.

Assess the client's condition per hospital protocol.

Which assessments should the nurse perform while assisting an older adult with housing needs? Select all that apply. Assessing financial status Assessing meaningful activities and interest Assessing environmental hazards and support systems Assessing long range plans such as wills and advance directives Assessing access to public transportation and community activities

Assessing financial status; Assessing environmental hazards and support systems; Assessing access to public transportation and community activities

A nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. To protect the caregivers from injury, the nurse teaches them to lift the client by first placing their arms under the client's axillae and doing what next? Bending and then straightening their knees Bending at the waist and then straightening the back Placing one foot in front of the other and then leaning back Placing pressure against the client's axillae and then raising their arms

Bending and then straightening their knees

How can nurses exhibit the concept of open-mindedness as a part of critical thinking behavior in their teams? Select all that apply. By being organized and focused By working with cognitive maturity By seeking the true meaning of any situation By respecting the right of others to have different opinions By becoming sensitive to the possibility of their own prejudices

By respecting the right of others to have different opinions By becoming sensitive to the possibility of their own prejudices

Which complication does the nurse prevent by addressing the needs of a hyperventilating client? Cardiac arrest Carbonic acid deficit Reduction in serum pH Excess oxygen saturation

Carbonic acid deficit

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? Airborne precautions Droplet precautions Contact precautions Protective environment

Contact precautions

A client complains of anxiety before a diagnostic procedure. The nurse explores and collects a thorough assessment to find the reason for client's anxiety. Which critical thinking attitude is involved in this situation? Discipline Confidence Responsibility Thinking independently

Discipline

Which intervention by the nurse helps the family feel in control when the client is to be discharged home? Instruct the family to ensure the client's room is safe. Ask the family to ensure that the client has only low-fat meals. Ask the family to coordinate with the staff at the rehabilitation center. Ensure a family member is confident about changing dressings correctly.

Ensure a family member is confident about changing dressings correctly.

A nurse is transcribing a practitioner's orders for a group of clients. Which order should the nurse clarify with the practitioner? Discharge in am Blood glucose monitoring ac and bedtime Erythromycin 250 mg TIW Dalteparin 5000 international units Sub-Q BID

Erythromycin 250 mg TIW

A client has an open reduction and internal fixation of the hip. The client is to be transferred to a chair for a half hour on the second postoperative day. Before transferring the client, what should the nurse do? Assess the strength of the affected leg. Explain the transfer procedure step by step. Instruct the client to bear weight evenly on both legs. Encourage the client to keep the affected leg elevated

Explain the transfer procedure step by step.

The registered nurse is teaching a nursing student to use self-disclosure appropriately to promote a therapeutic alliance with the client. Which carative factor is involved in this situation? Instilling faith-hope Forming a human-altruistic value system Promoting and expressing positive and negative feelings Developing a helping, trusting, and human caring relationship

Forming a human-altruistic value system

A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions? Postural drainage Cupping the chest Nasotracheal suctioning Frequent changes of position

Frequent changes of position

The nurse provides care for a Chinese client who is experiencing leg pain. The client states, "I don't want to take any medication that I may get addicted to." What is the best nursing intervention in this situation? Give ibuprofen (Advil) to the client with hot tea Give morphine (Avinza) to the client with hot tea Give ibuprofen (Advil) to the client with cold water Postpone medication administration to the client

Give ibuprofen (Advil) to the client with hot tea

A client is instructed to avoid straining on defecation postoperatively. Which food item chosen by the client indicates successful learning? Ripe bananas Milk products Green vegetables Creamed potatoes

Green vegetables

A client with limited mobility is being discharged. To prevent urinary stasis and formation of renal calculi, what should the nurse instruct the client to do? Increase oral fluid intake to 2 to 3 L/day. Maintain bed rest after discharge. Limit fluid intake to 1 L/day. Void at least every hour.

Increase oral fluid intake to 2 to 3 L/day.

The nurse starts a new job and recognizes that the client population is very diverse. What action will help the nurse to provide culturally competent care? Read about all of the cultural groups in the local population. Treat all of the clients the same, regardless of their cultural background. Increase self-awareness of cultural identity, cultural knowledge, and potential biases. Attempt to remain culturally neutral while treating clients of a different culture.

Increase self-awareness of cultural identity, cultural knowledge, and potential biases.

When meeting the unique preoperative teaching needs of an older adult, the nurse plans a teaching program based on which principle about learning? It reduces general anxiety. It is negatively affected by aging. It requires continued reinforcement. It necessitates readiness of the learner.

It requires continued reinforcement.

A nurse is helping a client who observes the traditional Jewish dietary laws to prepare a dietary menu. What considerations should the nurse make? Eating beef and veal is prohibited. Consumption of fish with scales is forbidden. Meat and milk at the same meal are forbidden. Consuming alcohol, coffee, and tea are prohibited.

Meat and milk at the same meal are forbidden.

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 what? White blood cell (WBC) count of 8200/mm 3 (8.2 X 10 9/L) Bilateral 3+ pitting pedal edema Oral temperature of 101.3° F (38.5° C) Pale skin and nail beds

Oral temperature of 101.3° F (38.5° C)

In the orientation phase, a nurse and a client meet and get to know each other. Which actions should the nurse follow in this phase? Select all that apply. Prioritizing the client's problems Clarifying the client's and nurse's roles Evaluating goal achievement with the client Taking action to meet goals set with the client Encouraging and helping the client with self-exploration

Prioritizing the client's problems Clarifying the client's and nurse's roles

An older adult in an acute care setting is having urinary incontinence. Which interventions would help the client? Select all that apply. Provide nutritional support Provide voiding opportunities Avoid indwelling catheterization Provide beverages and snacks frequently Promote measures to prevent skin breakdown

Provide voiding opportunities Avoid indwelling catheterization Promote measures to prevent skin breakdown

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 the care? Obtain a pulse oximeter to determine the client's oxygen saturation level. Put the client in a high Fowler position. Darken the lights and provide a rest period of at least 15 minutes. Continue the hygiene activities while reassuring the client.

Put the client in a high Fowler position.

A client is being discharged from the hospital with an indwelling urinary catheter. The client asks about the best way to prevent infection and keep the catheter clean. Which would be appropriate for the nurse to include in the client teaching? Once a day, clean the tubing with a mild soap and water, starting at the drainage bag and moving toward the insertion site. After cleaning the catheter site, it is important to keep the foreskin pushed back for 30 minutes to ensure adequate drying. Clean the insertion site daily using a solution of one part vinegar to two parts water. Replace the drainage bag with a new bag once a week.

Replace the drainage bag with a new bag once a week.

A client has been placing used insulin needles in a container sealed with heavy-duty tape. The client asks where the container can be disposed of. How should the nurse respond? Take it to the local hazardous waste collection site. Place it in the regular household trash. Take it to the local health department for disposal. Mail it to the Environmental Protection Agency (EPA).

Take it to the local hazardous waste collection site.

A nurse is caring for a 9-month-old infant with severe dehydration. What does the nurse expect to note while completing a physical assessment of this infant? Frothy stools Weak, rapid pulse Pale, copious urine Bulging anterior fontanel

Weak, rapid pulse

A nurse is teaching the parents of a school-aged child with celiac disease about the nutrients that must be avoided in a gluten-free diet. What nutrients should the nurse teach the parents to avoid? Saturated oils and fats Milk and hard cheeses Corn and rice products Wheat and oat products

Wheat and oat products

The registered nurse is teaching a nursing student about nursing care principles for cognitively impaired older adults. Which statement made by the nursing student indicates a need for further education? "I should encourage fluid intake." "I should provide conditional positive support." "I should promote social interaction based on abilities." "I should provide ongoing assistance to family caregiver."

"I should provide conditional positive support."

For which illness should airborne precautions be implemented? 1- Influenza 2- Chickenpox 3- Pneumonia 4- Respiratory syncytial virus

2- Chickenpox

Which nursing action should be included in the plan of care for a child with acute poststreptococcal glomerulonephritis? 1- Encouraging fluids 2- Monitoring for seizures 3- Measuring abdominal girth 4- Checking for pupillary reactions

2- Monitoring for seizures

Which nursing interventions indicate client care that supports physical functioning? Select all that apply. 1- Interventions to facilitate client's learning 2- Interventions to alter client's undesirable behavior 3- Interventions to maintain client's nutritional status 4- Interventions to maintain client's regular bowel patterns 5- Interventions to prevent complications in the client related to electrolyte imbalance

3 & 4 3- Interventions to maintain client's nutritional status 4- Interventions to maintain client's regular bowel patterns

A 10-year-old child is admitted to the pediatric unit in vaso-occlusive sickle cell crisis. The nurse manager is planning to assign a room. Which child is the best roommate option for this client? 1- Child with thalassemia 2- Child with osteomyelitis 3- Child with viral pneumonia 4- Child with acute pharyngitis

1- Child with thalassemia

A client is admitted to the hospital with a tentative diagnosis of infectious pulmonary tuberculosis. What infection control measures should the nurse take? 1- Don an N95 respirator mask before entering the room. 2- Put on a permeable gown each time before entering the room. 3- Implement contact precautions and post appropriate signage. 4- After finishing with client care, remove the gown first and then remove the gloves.

1- Don an N95 respirator mask before entering the room.

Which nurse collaborates directly with the client to establish and implement a basic plan of care after admission? 1- Primary nurse 2- Nurse clinician 3- Nurse coordinator 4- Clinical nurse specialist

1- Primary nurse

Which psychophysiologic factors can influence communication between a nurse and a client? Select all that apply. 1- Privacy level 2- Emotional status 3- Information exchange 4- Level of caring expressed 5- Growth and development

2 & 5; Emotional status & Growth and development

A client is admitted voluntarily to a psychiatric unit. Later, the client develops severe pain in the right lower quadrant and is diagnosed as having acute appendicitis. How should the nurse prepare the client for the appendectomy? Have two nurses witness the client signing the operative consent form. Ensure that the primary healthcare provider and the psychiatrist sign for the surgery because it is an emergency procedure. Ask the client to sign the operative consent form after the client has been informed of the procedure and required care. Inform the client's next of kin that it will be necessary for one of them to sign the consent form because the client is on a psychiatric unit.

sk the client to sign the operative consent form after the client has been informed of the procedure and required care.

The nurse at the well baby clinic is assessing the gross motor skills of a five-month-old infant. Which finding is a cause for concern? 1- The baby has a head lag when pulled to sit. 2- The baby can turn from the side to the back. 3- The baby can turn from the abdomen to the back. 4- The baby supports much of his own weight when he or she is pulled to stand.

1- The baby has a head lag when pulled to sit.

Which assessment finding is associated with depression? 1- The client has islands of intact memory. 2- The client has impaired recent and remote memory. 3- The client has impaired recent and immediate memory. 4- The client needs step-by-step instructions for simple tasks.

1- The client has islands of intact memory.

Which approach is a comforting approach that communicates concern and support? 1- Touching 2- Mirroring 3- Knowing the client 4- Providing presence

1- Touching

A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L (122 mmol/L) and a potassium level of 3.6 mEq/L (3.6 mmol/L). Based on the lab results and symptoms, what is the client experiencing? 1- Hypernatremia 2- Hyponatremia 3- Hyperkalemia 4- Hypokalemia

2- Hyponatremia

A nurse in the emergency department is caring for a 9-year-old child with a suspected spinal cord injury sustained while falling off a bicycle. What is the initial nursing action? 1- Placing the child's head on a pillow for support 2- Immobilizing the child's spine to limit additional injury 3- Log-rolling the child to check for lacerations on the back 4- Moving the child onto a firm stretcher for transport to the radiography department

2- Immobilizing the child's spine to limit additional injury

The mother of a 4-month-old infant weighing 11 lb (5 kg) asks the nurse how much formula is required per day now that her baby has been weaned from the breast. The recommended caloric intake is 108 kcal/kg, and the formula contains 20 kcal/oz (20 kcal/30 mL). How much formula should the nurse tell the mother to give to her infant each day? 21 oz (630 mL) 27 oz (810 mL) 33 oz (990 mL) 39 oz (1170 mL)

27 oz (810 mL) Rationale The infant's daily intake should be approximately 27 oz (810 mL). The infant weighs 11 lb (11/2.2 = 5 kg). An infant's daily caloric need is 108 kcal/kg body weight. 108 kcal × 5 kg = 540 kcal/day; because there are 20 kcal/oz, 540 ÷ 20 = 27 oz (20 kcal/30 mL, 540 ÷ 20 X 30 mL = 810 mL) . Twenty-one ounces (630 mL) is inadequate; 33 (990 mL) oz or 39 (1170 mL) oz is excessive.

A community healthcare nurse is conducting a survey about homeless children in the community. Which finding helps the nurse distinguish absolute homelessness from relative homelessness? 1- The children are under-immunized and at a risk for childhood illnesses. 2- The children are more likely to drop out of school and become unemployable. 3- The children have access to healthcare only through the emergency department. 4- The children do not have a physical shelter and may sleep outdoors or in vehicles.

4- The children do not have a physical shelter and may sleep outdoors or in vehicles.

Which nursing intervention can be classified under complex physiologic domain according to the Nursing Interventions Classification (NIC) taxonomy? Select all that apply. 1- Interventions to restore tissue integrity 2- Interventions to optimize neurologic functions 3- Interventions to manage restricted body movements 4- Interventions to promote comfort using psychosocial techniques 5- Interventions to provide care before, during, and immediately after surgery

1, 2, &5 1- Interventions to restore tissue integrity 2- Interventions to optimize neurologic functions 5- Interventions to provide care before, during, and immediately after surgery

An adolescent girl is concerned about her body image after amputation of a leg for bone cancer. After the nurse has obtained the girl's consent, what nursing action is most therapeutic? 1- Encouraging her peers to visit 2- Keeping her lower body covered 3- Placing her in a room by herself 4- Limiting her visitors to the family

1- Encouraging her peers to visit

On the second day of hospitalization a client is discussing with the nurse concerns about unhealthy family relationships. During the nurse-client interaction the client begins to talk about a job problem. The nurse's response is, "Let's go back to what we were just talking about." What therapeutic communication technique did the nurse use? 1- Focusing 2- Restating 3- Exploring 4- Accepting

1- Focusing

A nurse is caring for a young, hyperactive child with attention deficit-hyperactivity disorder who engages in self-destructive behavior. What is the most important nursing objective in the planning of care for this child? 1- Keeping the child from inflicting any self-injury 2- Helping the child improve communication skills 3- Helping the child formulate realistic ego boundaries 4- Providing the child with opportunities to discharge energy

1- Keeping the child from inflicting any self-injury

Which of these age groups has the highest incidence of lead poisoning? 1- Adult 2- Toddler 3- Adolescent 4- School-age child

2- Toddler

A hospitalized client is scheduled to have a sigmoidoscopy. The nurse anticipates that preprocedure prescriptions will include what? Providing instructions about restraints used during the procedure Administering a Fleet enema 1 hour before the procedure Encouraging increased intake of clear fluids Administering morphine 30 minutes before the procedure

Administering a Fleet enema 1 hour before the procedure

A 93-year-old client in a nursing home has been eating less food during mealtimes. What is the priority nursing intervention? Substitute a supplemental drink for the meal. Spoon-feed the client until the food is completely eaten. Allow the client a longer period of time to complete the meal. Arrange a consultation for the placement of a gastrostomy tube.

Allow the client a longer period of time to complete the meal.

While caring for a family, the nurse finds that the family has accepted the shifts of generational roles. Which change in the family status for proceeding developmentally would the nurse observe? Dealing with retirement Taking on parental roles Adjusting to a reduction in family size Refocusing on midlife material and career issues

Dealing with retirement

A nurse is planning care for a client with substance-induced persisting dementia resulting from long-term alcohol use. Which nutritional problem, in addition to the effect of alcohol on brain tissue, has contributed to substance-induced persisting dementia? Increase in serotonin Deficiency of thiamine Reduction in iron intake Malabsorption of riboflavin

Deficiency of thiamine

A nurse provides crutch-walking instructions to a client who has a left-leg cast. The nurse should explain that weight must be placed where? In the axillae On the hands On the right side On the side that the client prefers

On the hands

The healthcare provider prescribes a low-fat, 2-gram sodium diet for a client with hypertension. The nurse should explain that the purpose of restricting sodium is to do what? Chemically stimulate the loop of Henle Diminish the thirst response of the client Prevent reabsorption of water in the distal tubules Cause fluid to move toward the interstitial compartment

Prevent reabsorption of water in the distal tubules

While talking with a 60-year-old client, the nurse learns that the client emigrated 15 years ago from China and likes to live independently away from the client's grown children. The client eats only Chinese foods at home. What should the nurse infer from these findings? The client has undergone assimilation. The client has undergone biculturalism. The client has undergone acculturation. The client has undergone enculturation.

The client has undergone biculturalism.

A client being treated for influenza A (H1N1) is scheduled for a computed tomography (CT) scan. To ensure client and visitor safety during transport, the nurse should take which precaution? 1- Place a surgical mask on the client. 2- Other than standard precautions, no additional precautions are needed. 3- Minimize close physical contact. 4- Cover the client's legs with a blanket.

1- Place a surgical mask on the client.

Which nursing action would be considered a part of self-regulation in the decision-making process? 1- Reflecting on one's own experiences 2- Looking at all the situations objectively 3- Supporting findings and conclusions 4- Making careful assumptions about a client's information

1- Reflecting on one's own experiences

Which action made by the client indicates that they are in the precontemplation stage of Transtheoretical Model of Change? 1- Refuses to think about changing 2- Intends to change in the next 60 days 3- Sustains the changed action for 6 months 4- Recognizes the advantages of the change

1- Refuses to think about changing

A postpartum nurse is reviewing principles related to automobile infant restraint systems with the parents of a newborn who is to be discharged in the morning. What information should be included in the teaching session? Select all that apply. 1- Use a forward-facing infant car seat. 2- Secure the infant seat so that it faces the rear. 3- Position the seat between the driver's and passenger's seats in the front seat. 4- Follow the manufacturer's directions to secure the infant seat in the back seat. 5- Be sure to follow weight guidelines set forth in the manufacturer's instructions.

2, 4, & 5 2- Secure the infant seat so that it faces the rear. 4- Follow the manufacturer's directions to secure the infant seat in the back seat. 5- Be sure to follow weight guidelines set forth in the manufacturer's instructions.

Which description is most appropriate for the family centered care approach? 1- The nursing care is focused on the client as an individual. 2- A collaborative plan of care is developed to achieve optimal health. 3- The healthcare provider is the expert in developing a plan of care. 4- The nursing care is based solely on standards of practice.

2- A collaborative plan of care is developed to achieve optimal health.

A client is going for a magnetic resonance imaging (MRI). What should the nurse ascertain before taking the client to the procedure? 1- Scheduled medications have been given. 2- All metal, such as jewelry and hair ornaments, has been removed. 3- Adequate prehydration has been given. 4- The client has emptied the bladder.

2- All metal, such as jewelry and hair ornaments, has been removed.

An advanced practice registered nurse (APRN) is caring for a pregnant woman. Which type of APRN would care for this client? 1- Clinical nurse specialist (CNS) 2- Certified nurse midwife (CNM) 3- Certified nurse practitioner (CNP) 4- Certified registered nurse anesthetist (CRNA)

2- Certified nurse midwife (CNM)

The nurse is measuring the body temperature of four clients in a clinical setting. Which client is in need of rewarming through cardiopulmonary bypass? 1- Client A: 94.2 F 2- Client B: 85.3 F 3- Client C: 89.4 F 4- Client D: 91.5 F

2- Client B: 85.3 F

A home health nurse on a first visit checks the client's vital signs and obtains a blood sample for an international normalized ratio (INR). After these tasks are completed, 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."

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia? 1- Red blood cell count 2- Sputum culture 3- Arterial blood gas 4- Total hemoglobin

3- Arterial blood gas

One afternoon the nurse on the unit overhears a young female client having an argument with her boyfriend. A while later the client complains to the nurse that dinner is always late and the meals are terrible. The nurse identifies the defense mechanism that the client is using as what? 1- Projection 2- Dissociation 3- Displacement 4- Intellectualization

3- Displacement

A nurse is reviewing how a hyperglycemic client's blood glucose can be lowered. The nurse recalls that the chemical that buffers the client's excessive acetoacetic acid is what? 1- Potassium 2- Sodium bicarbonate 3- Carbon dioxide 4- Sodium chloride

2- Sodium bicarbonate

Which stage of Piaget's theory of cognitive development does the nurse observe in a preschooler? 1- Sensorimotor 2- Preoperational 3- Formal operations 4- Concrete operations

2- Preoperational

The nurse manager asks the nurse, "How would you implement clinical decision making in a group of clients?" Which answer provided by the nurse shows effective critical thinking? Select all that apply. "I will avoid involving clients as decision-makers and participants in care." "I will discuss complex cases with other members of the healthcare team." "I will identify the nursing diagnoses and collaborative problems of each client." "I will consider the period it takes to care for clients whose problems have higher priority." "I will decide to perform activities individually to resolve more than one client problem at a time."

"I will discuss complex cases with other members of the healthcare team." "I will identify the nursing diagnoses and collaborative problems of each client." "I will consider the period it takes to care for clients whose problems have higher priority."

A post-operative client is discharged to home. Which statement made by the nurse would be beneficial for the client's care in the home? "I will change the dressing every day." "I will recommend a physical therapy referral." "I will provide you with a homecare service referral." "I will not allow any family member to be present during dressing change."

"I will provide you with a homecare service referral."

A client who has been battling cancer of the ovary for 7 years is admitted to the hospital in a debilitated state. The healthcare provider tells the client that she is too frail for surgery or further chemotherapy. When making rounds during the night, the nurse enters the client's room and finds her crying. Which is the most appropriate intervention by the nurse? 1- Sit down quietly next to the bed and allow her to cry. 2- Pull the curtain and leave the room to provide privacy for the client. 3- Explain to the client that her feelings are expected and they will pass with time. 4- Observe the length of time the client cries and document her difficulty accepting her impending death.

1- Sit down quietly next to the bed and allow her to cry.

A client who wakes up after a surgery spits out the oral airway placed during the recovery from anesthesia. What does this behavior indicate to the nurse? 1- The client's gag reflex has returned. 2- The client is confused due to anesthesia. 3- The client is nauseated and wants to vomit. 4- The client's airway is becoming obstructed.

1- The client's gag reflex has returned.

A client with paralysis of the legs is found to have somatoform disorder, conversion type. What must the nurse consider when formulating a plan of care for this client? 1- The illness is very real to the client and requires appropriate nursing care. 2- Although the client believes that there is an illness, there is no cause for concern. 3-There is no physiological basis for the illness; therefore only emotional care is needed. 4- Nursing intervention is needed even though the nurse understands that the client is not ill.

1- The illness is very real to the client and requires appropriate nursing care.

Which professional standard does the nurse feel is most important for critical thinking? 1- Logical thinking 2- Evaluation criteria 3- Accurate knowledge 4- Relevant information

2- Evaluation criteria

After changing a dressing that was used to cover a draining wound on a client with vancomycin-resistant enterococci (VRE), the nurse should take which step to ensure proper disposal of the soiled dressing? 1- Place the dressing in the bedside trash can. 2- Place the dressing in a red bag/hazardous materials bag. 3- Contact Environmental Services personnel to pick up the dressing. 4- Transport the dressing to the laboratory to be placed in the incinerator.

2- Place the dressing in a red bag/hazardous materials bag.

A nurse is taking the vital signs of a client who has just been admitted to the healthcare facility. Which intervention by the nurse provides greater client satisfaction? 1- The nurse records the vital signs and leaves the room. 2- The nurse adjusts the bed and asks if the client is comfortable. 3- The nurse leaves the door of the room open while attending to the client. 4- The nurse tells the client that the primary healthcare provider will visit soon

2- The nurse adjusts the bed and asks if the client is comfortable.

A nurse is caring for a client who is angry and agitated. What is the best approach for the nurse to use with this client? 1- Confronting the client about the behavior 2- Turning on the television to distract the client 3- Maintaining a calm, consistent approach with the client 4- Explaining to the client why the behavior is unacceptable

3- Maintaining a calm, consistent approach with the client

A nurse is caring for a 13-year-old child who has an external fixation device on the leg. What is the nurse's priority goal when providing pin care? 1- Easing pain 2- Minimizing scarring 3- Preventing infection 4- Preventing skin breakdown

3- Preventing infection

Which component of decision-making refers to the duties and activities an individual is employed to perform? 1- Authority 2- Autonomy 3- Responsibility 4- Accountability

3- Responsibility

An 80-year-old client is admitted to the hospital because of complications associated with severe dehydration. The client's daughter asks the nurse how her mother could have become dehydrated, because she is alert and able to care for herself. The nurse's best response is: 1- "The body's fluid needs decrease with age because of tissue changes." 2- "Access to fluid may be insufficient to meet the daily needs of the older adult." 3- "Memory declines with age, and the older adult may forget to ingest adequate amounts of fluid." 4- "The thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased."

4- "The thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased."

A client exhibits physical symptoms in response to stress. What nursing intervention may help the client reduce this physiological response to stress? 1- Limiting discussions about the problem 2- Providing information regarding medical care 3- Teaching the client how to eliminate stress at home 4- Assisting the client in developing new coping mechanisms

4- Assisting the client in developing new coping mechanisms

The nurse is assessing a Latino-Caribbean client who was brought to the hospital by family members. The family reports the client started crying, shouting, trembling, had uncontrolled jerking of the extremities, and then fell into a trance-like state. What condition does the nurse suspect? 1- Bulimia nervosa 2- Anorexia nervosa 3- Shenjing shuairuo 4- Ataque de nervios

4- Ataque de nervios

A nurse is reviewing a client's plan of care. What is the determining factor in the revision of the plan? 1- Time available for care 2- Validity of the problem 3- Method for providing care 4- Effectiveness of the interventions

4- Effectiveness of the interventions

Which statement is true about the nursing model "team nursing"? 1- The registered nurse is responsible for all aspects of client care. 2- Client care can be delegated to other healthcare team members. 3- The registered nurse works directly with the client, family members, and healthcare team members. 4- Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members.

4- Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members.

The nurse is performing nursing care therapies and including the client as an active participant in the care. Which basic step is involved in this situation? 1- Planning 2- Evaluation 3- Assessment 4- Implementation

4- Implementation

What teaching must the nurse emphasize to the family when preparing a school-aged child with persistent asthma for discharge? 1- A cold, dry environment is desirable. 2- Limits should not be placed on the child's behavior. 3- The health problem is gone when symptoms subside. 4- Medications must be continued even when the child is asymptomatic.

4- Medications must be continued even when the child is asymptomatic.

Which right of delegation refers to the giving of clear, concise descriptions of a task to the delegatee? 1- Right task 2- Right person 3- Right supervision 4- Right communication

4- Right communication

The nurse is developing a plan of care for the client who has activity intolerance. In determining the desired client outcomes, what should the nurse do? 1- Prioritize psychosocial needs over physical needs. 2- Use the Nursing Outcomes Classification (NOC) only. 3- Use nursing knowledge to plan outcomes and disregard client and family desires. 4- Set priorities and outcomes using the client's and family input.

4- Set priorities and outcomes using the client's and family input.

Which activity would the nurse explain can be performed by infants of aged 6 to 8 months? 1- Holding a pencil 2- Showing hand preference 3- Placing objects into containers 4- Transferring objects from hand to hand

4- Transferring objects from hand to hand

The nurse is preparing to perform endotracheal suctioning of a client with respiratory difficulties. Before beginning the procedure, what should the nurse do? Ask the client to take several deep breaths. Instruct the client to cough before suctioning. Administer 100% oxygen to the client. Change the suctioning equipment to ensure sterility.

Administer 100% oxygen to the client.

Which nursing intervention is performed for a middle-aged adult in restorative and continuing care? Establishing independence Focusing on problems related to sense of identity Reorganizing intimate relationships and family structure Determining the coping mechanisms of the client and the family

Determining the coping mechanisms of the client and the family

Which description relates to Gesell's theory of development? Select all that apply. One growth pattern is common to all children. Only genetic factors direct the sequence of development. Growth in humans is both cephalocaudal and proximodistal. Growth is maximized only if environmental conditions are adequate. The pattern of maturation follows a fixed developmental sequence in humans.

Growth in humans is both cephalocaudal and proximodistal. Growth is maximized only if environmental conditions are adequate. The pattern of maturation follows a fixed developmental sequence in humans.

A nurse is caring for a female client during the manic phase of bipolar disorder. What should the nurse do to help the client with personal hygiene? Suggest that she wear hospital clothing. Guide her to dress appropriately in her own clothing. Allow her to apply makeup in whatever manner she chooses. Keep makeup away from her because she will apply it too freely.

Guide her to dress appropriately in her own clothing.

Which nursing interventions can help a terminally ill client cope with feelings related to death? Select all that apply. Providing medications and therapies for pain management Teaching the client about importance of complementary medicine Helping the client to find meaning and purpose in life by listening to his or her concerns Allowing time for religious readings, spiritual visitations, or attendance at religious services Encouraging the client to pray if he or she wishes by facilitating privacy and a proper environment

Helping the client to find meaning and purpose in life by listening to his or her concerns Allowing time for religious readings, spiritual visitations, or attendance at religious services Encouraging the client to pray if he or she wishes by facilitating privacy and a proper environment

A client becomes hostile when learning that amputation of a gangrenous toe is being considered. After the client's outburst, what is the best indication that the nurse-client interaction has been therapeutic? Increased physical activity Absence of further outbursts Relaxation of tensed muscles Denial of the need for further discussion

Relaxation of tensed muscles

A nurse is providing postoperative teaching to a client who is scheduled to have an above-the-knee amputation. The client will use crutches during the postoperative period. Which activity will prepare the client for crutch walking? Lifting weights Changing bed positions Caring for the residual limb

Lifting weights

Which nursing action is a part of the evaluation phase of the critical thinking process? Select all that apply. Collecting all the data in order Looking at all the situations objectively Support the findings and drawing conclusions Be open-minded to information about a client Using several criteria to determine the effectiveness of a nursing intervention

Looking at all the situations objectively & Using several criteria to determine the effectiveness of a nursing intervention

While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the nurse take? Immediately stop the infusion. Lower the height of the enema bag. Advance the enema tubing 2 to 3 inches (5 to 7.5 cm). Clamp the tube for 2 minutes and then restart the infusion.

Lower the height of the enema bag.

A client with hemiparesis is reluctant to use a cane. How does the nurse explain the cane's purpose to the client? Maintain balance to improve stability Relieve pressure on weight-bearing joints Prevent further injury to weakened muscles Aid in controlling involuntary muscle movements

Maintain balance to improve stability

A nurse is caring for a client who has a Hemovac portable wound suction device after abdominal surgery. What is the reason why the nurse empties the device when it is half full? Emptying the unit is safer when it is half full. Accurate measurement of drainage is facilitated. Negative pressure in the unit lessens as fluid accumulates, interfering with further drainage. Fluid collecting in the unit exerts positive pressure, forcing drainage back up the tubing and into the wound.

Negative pressure in the unit lessens as fluid accumulates, interfering with further drainage.

After surgery for a fractured hip, a client states, "I don't remember when I have ever been so uncomfortable." What should the nurse's initial response be? Notify the primary healthcare provider. Use distraction techniques. Medicate the client as prescribed. Perform a complete pain assessment.

Perform a complete pain assessment.

A nurse assesses a client's serum electrolyte levels in the laboratory report. What electrolyte in intracellular fluid should the nurse consider most important? Sodium Calcium Chloride Potassium

Potassium

The nurse develops a goal that makes a client feel as if the client is engaging in a competition. Which type of motivation is the nurse using in this situation? Power motivation Affiliative motivation Avoidance motivation Achievement motivation

Power motivation

A nurse is providing dietary teaching for a client with celiac disease. Which foods should the nurse teach the client to avoid when following a gluten-free diet? Select all that apply. Rye Oats Rice Corn Wheat

Rye, Oats, Wheat

A nurse considers that communication links people with their surroundings. What should the nurse identify as the most important communication link? Social Physical Materialistic Environmental

Social