Evolve Fundamentals - Basics

A visitor says to the nurse, "Can I read my client's progress record? I am the sponsor from an alcohol recovery program." How should the nurse respond?

Do not allow the sponsor to review the record

What effect of povidone-iodine (Betadine) does a nurse consider when using it on the client's skin before obtaining a specimen for a blood culture?

Eliminates surface bacteria that may contaminate the culture

A nurse overhears an unlicensed assistive personnel (UAP) talking with a client about the client's marital and family problems. The nurse identifies that the UAP is providing false reassurance when the UAP states:

"Everything will be fine, just wait and see."

A nurse instructs a client to breathe deeply to open collapsed alveoli. What should the nurse include in the explanation of the relationship between alveoli and improved oxygenation?

"Oxygen is exchanged for carbon dioxide in the alveolar membrane.

A nurse discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a history of alcoholism. What need must self-help groups such as AA meet to be successful?

Belonging

A health care provider prescribes a vitamin tablet that contains vitamin B complex. What should the nurse teach the client?

It may turn the urine bright yellow.

A client expresses concern about being exposed to radiation therapy because it can cause cancer. What should the nurse emphasize when informing the client about exposure to radiation?

Only a small part of the body is irradiated.

The nurse is providing information about blood pressure to Unlicensed Assistive Personnel (UAP) and recalls that the factor that has the greatest influence on diastolic blood pressure is:

Peripheral vascular resistance

Nursing actions for the older adult should include health education and promotion of self-care. Which is most important when working with the older adult client?

Reinforcing the client's strengths and promoting reminiscing

The nurse creates a plan of care for a client with a risk of infection. Which is the most desirable expected outcome for the client?

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

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?

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

A hospitalized client is scheduled to have a sigmoidoscopy. The nurse anticipates that pre-procedure prescriptions will include:

Administering a fleet enema 1 hour before the procedure

Which task is most appropriate for a nurse to delegate to unlicensed assistive personnel?

Assessing the blood pressure of a client before physical therapy.

While instructing a community group regarding risk factors for coronary artery disease, the nurse provides a list of risk factors that cannot be modified. What should be included on the list?

Heredity

In all states of the United States, what is the professional nurse's legal responsibility regarding child abuse?

Report any suspected abuse to local law enforcement authorities

The nurse administers a pneumococcal vaccine to a 70-year-old client. The client asks "Will I have to get this every year like I do with the flu shot?" How should the nurse respond?

"It is unnecessary to have any follow-up injections of the pneumococcal vaccine after this dose.

A nurse is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure? (Select all that apply.)

Clean the eyelid and eyelashes Apply clean gloves before beginning of procedure Press on the nasolacrimal duct after instilling the solution

How can a nurse best evaluate the effectiveness of communication with a client?

Client feedback

A client with hypothermia is brought to the emergency department. What treatment does the nurse anticipate when the patient is in the emergency department?

Core rewarming with warm fluids

Health promotion efforts with the chronically ill client should include interventions related to primary prevention. What should this include?

Encouraging daily physical exercise

When being interviewed for a position as a licensed practical nurse, the applicant is asked to identify an example of an intentional tort. What is the appropriate response?

False imprisonment

An obese adult develops an abscess after abdominal surgery. The wound is healing by secondary intention and requires repacking and redressing every four hours. Which diet should the nurse expect the health care provider to prescribe to best meet this client's immediate nutritional needs?

High in protein and vitamin C

A day after an explanation of the effects of surgery to create an ileostomy, a 68-year-old male client remarks to the nurse, "It will be difficult for my wife to care for a helpless old man." This comment by the client regarding himself is an example of Erikson's conflict of:

Integrity versus despair

A client is placed on a stretcher and restrained with straps while being transported to the x-ray department. A strap breaks, and the client falls to the floor, sustaining a fractured arm. Later the client shows the strap to the nurse manager, stating, "See, the strap is worn just at the spot where it snapped." What is the nurse's accountability regarding this incident?

Liable, along with the employer, for misapplication of equipment or use of defective equipment that harms the client

A nurse is helping a client who observes the traditional Jewish dietary laws to prepare a dietary menu. What considerations should the nurse make?

Meat and milk at the same meal are forbidden.

A client with a terminal illness reaches the stage of acceptance. How can the nurse best help the client during this stage?

Stay nearby without initiating conversation

A nurse is caring for a client diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA) in the urine. The health care provider orders an indwelling urinary catheter to be inserted. Which precaution should the nurse take during this procedure?

Surgical asepsis

A client comes to the clinic complaining of a productive cough with copious yellow sputum, fever, and chills for the past two days. The first thing the nurse should do when caring for this client is to:

Take the temperature

After several weeks of caring for clients who are in the terminal stage of illness, the nurse becomes aware of feeling depressed when coming to work. What should the nurse do?

Talk with other nurses on the unit

A client has been diagnosed as "brain dead". The nurse understands that this means that the client has:

no cortical functioning with some reflex breathing

Nurses are held responsible for the commission of a tort. The nurse understands that a tort is:

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

A nurse in the health clinic is counseling a college student who recently was diagnosed with asthma. On what aspect of care should the nurse focus?

Evaluating whether the necessary lifestyle changes are understood

A nurse fails to act in a reasonable, prudent manner. Which legal principle is most likely to be applied?

Malpractice

Alternative therapy measures have become increasingly accepted within the past decade, especially in the relief of pain. Which methods qualify as alternative therapies for pain? (Select all that apply.)

Prayer Hypnosis Aromatherapy Guided imagery

A toddler screams and cries noisily after parental visits, disturbing all the other children. When the crying is particularly loud and prolonged, the nurse puts the crib in a separate room and closes the door. The toddler is left there until the crying ceases, a matter of 30 or 45 minutes. Legally, how should this behavior be interpreted?

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

What should the nurse include in dietary teaching for a client with a colostomy?

The diet should be adjusted to include foods that result in manageable stools

A client has a stage III pressure ulcer. Which nursing intervention can prevent further injury by eliminating shearing force?

With the help of another staff member, use a drawsheet when lifting the client in bed

What is a nurse's most appropriate response, based on current research, when asked about spanking as a disciplinary technique?

"Spanking is strongly suggestive of negative role modeling."

Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibit formation of aqueous humor for a client with glaucoma?

AcetaZOLAMIDE (Diamox)

A client is diagnosed with AIDS. When examining the client's oral cavity, the nurse assesses white patchy plaques on the mucosa. The nurse recognizes that this finding most likely represents what opportunistic infection?

Candida albicans

When changing the soiled bed linens of a client with a wound that is draining seropurulent material, what personal protective equipment (PPE) is most essential for the nurse to wear?

Clean gloves

Which nursing interventions require a nurse to wear gloves? (Select all that apply.)

Cleaning a newborn immediately after delivery. Emptying a portable wound drainage system.

The nurse recognizes that a common conflict experienced by the older adult is the conflict between:

Independence and dependence

The most effective time to teach clients who have sustained a sudden, traumatic, major loss is most often during the acceptance or adaptation stage of coping. The rationale for this fact is that clients in this stage are:

Less anxious and more aware of reality and therefore ready to learn

The nurse is caring for a surgical client who develops a wound infection during hospitalization. How is this type of infection classified?

Nosocomial

A physician orders a urinalysis for a client with an indwelling catheter. To ensure that an appropriate specimen is obtained, the nurse would obtain the specimen from which site?

tubing injection port

A nurse has provided discharge instructions to a client who received a prescription for a walker to use for assistance with ambulation. The nurse determines that the teaching has been effective when the client:

Moves the walker no more than 12 inches in front of the client during use

A nurse is hired to work in a health care facility that has a complete computer-based client information system. The nurse in charge knows that the newly hired nurse is knowledgeable about this system when the nurse says:

"Client information is immediately available when this system is used."

A nurse hired to work in a metropolitan hospital provides services for a culturally diverse population. One of the nurses on the unit says it is the nurses' responsibility to discourage "these people" from bringing all that "home medicine stuff" to their family members. Which response by the recently hired nurse is most appropriate?

"Nontraditional approaches to health care can be beneficial."

A complete blood count (CBC), urinalysis, and x-ray examination of the chest are prescribed for a client before surgery. The client asks why these tests are done. Which is the best reply by the nurse?

"They are done to identify other health risks."

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?

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

A nurse is reinforcing teaching to an adolescent about type 1 diabetes and self-care. Which questions from the client indicate a need for additional teaching in the cognitive domain? (Select all that apply.)

"What is diabetes? "Can you tell me how the glucose monitor works?"

The nurse is interviewing a client admitted for uncontrolled diabetes after binging on alcohol for the past two weeks. The client states "I am worried about how I am going to pay my bills for my family while I am hospitalized." Which statement by the nurse would best elicit information from the client?

"You are worried about paying your bills?"

A client who has reached the stage of acceptance in the grieving process appears peaceful, but demonstrates a lack of involvement with the environment. How should the nurse address this behavior?

Accept the behavior the client is exhibiting

When planning discharge teaching for a young adult, the nurse should include the potential health problems common in this age group. What should the nurse include in this teaching plan?

Accidents, including their prevention

A nurse is discussing Alcoholics Anonymous (AA) with a client. What behavior expected of members of AA should the nurse include in the discussion?

Acknowledging an inability to control the problem

A nurse is caring for a client for whom segmental postural drainage treatments are prescribed. The nurse should avoid scheduling the treatment at what time?

After a meal

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?

Arterial blood gas

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?

Assess the client's condition every hour

A terminally ill client is furious with one of the staff nurses. The client refuses the nurse's care and insists on doing self-care. A different nurse is assigned to care for the client. What should be the newly assigned nurse's initial step in revising the client's plan of care?

Assess the client's present status and include the client in a discussion of revisions to the plan of care.

A daughter of a Chinese-speaking client approaches a nurse and asks multiple questions while maintaining direct eye contact. What culturally related concept does the daughter's behavior reflect?

Assimilation

The nurse is having difficulty understanding a client's decision to have hospice care rather than an extensive surgical procedure. Which ethical principle does the client's behavior illustrate? 1 Justice

Autonomy

What should a nurse recommend to help a client best during the period immediately after a spouse's death?

Bereavement counseling

The nurse is caring for a client that 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 caused from

Bleeding posterior to the nasal packing

The nurse should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may:

Cause the device to pull away from the skin

Considering Erikson's developmental theories, a 21-year-old male client who has sustained a spinal injury below the level of T6 will most likely have difficulty with:

Developing meaningful relationships

A client comes to the medical clinic complaining of headaches. The nurse measures the blood pressure at 172/114. What should the nurse do first?

Elevate the head of the bed, provide reassurance, and reassess the blood pressure

A client with a leg prosthesis and a history of syncopal episodes is being admitted to the hospital. When formulating the plan of care for this client, the nurse should include that the client is at risk for:

Falls

A hospital has threatened to refuse the discharge of a newborn until the parents pay part of the hospital bill. The nurse is aware that the legal term that best describes this situation is:

False imprisonment

Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus?

Impaired neural functioning

A nurse is discussing weight loss with an obese individual with Ménière's disease. Which suggestion by the nurse is most important?

Keep a diary of all foods eaten each day.

A senior high school student, whose immunization status is current, asks the school nurse which immunizations will be included in the precollege physical. Which vaccine should the nurse tell the student to expect to receive?

Measles, mumps, rubella (MMR)

Nurses care for clients in a variety of age groups. In which age group is the occurrence of chronic illness the greatest?

Older adults

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:

Oral temperature of 101.3º F

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?

Relaxation of tensed muscles

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

Social

The nurse provides a client with left-sided weakness with instructions on how to safely use a cane. The nurse should demonstrate proper use of the cane by holding it on:

The right side

A postoperative client says to the nurse, "My neighbor—I mean the person in the next room—sings all night and keeps me awake." The neighboring client has dementia and is awaiting transfer to a nursing home. How can the nurse best handle this situation?

Move the post-operative client to a room at the end of the hall.

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?

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

A nurse is caring for a client that has been admitted with right sided heart failure. The nurse notes that the client has dependent edema around the area of the feet and ankles. In order to characterize the severity of the edema, the nurse presses the medial malleolus area and notes an 8 mm depression after release. This nurse understands that the edema should be documented as:

4+

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

5 ml

A client with respiratory difficulties asks why the percussion procedure is being performed. The nurse explains that the primary purpose of percussion is to:

Loosen pulmonary secretions

A client has been instructed to stop smoking. The nurse discovers a pack of cigarettes in the client's bathrobe. What is the nurse's initial action?

Tell the client that the cigarettes were found.

The nurse instructs a client with a new colostomy to avoid foods and drinks that produce a large amount of gas, and specifically to avoid the intake of:

Cabbage

When assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. The nurse places the client in the low-Fowler position with the knees slightly bent and encourages the client to lie still. What is the next nursing action?

Cover the wound with a sterile towel moistened with normal saline.

A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. This assessment should be documented as:

Crackles

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?

Focusing

A client experiences a muscle sprain of the ankle. When assessing the injury, the nurse discovers that a hematoma is developing, edema is present and that the client reports tenderness when the ankle is palpated. The nurse anticipates that the plan of care will include the applying of a/an:

Ice bag

A nurse identifies that an older adult has not achieved the desired outcome from a prescribed proprietary medication. When assessing the situation, the client shares that the medication is too expensive and the prescription was never filled. What is an appropriate nursing response?

Inform the health care provider of the inability to afford the medication.

A nurse receives abnormal results of diagnostic testing. What action should the nurse take first?

Notify the client's healthcare provider of the results

A nursing team leader identifies that a nurse is coming to work after drinking alcohol. What is the most appropriate way for the team leader to approach this ethical situation?

Notify the nurse manager about the problem.

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.

An 82-year-old retired schoolteacher is admitted to a nursing home. During the physical assessment, the nurse identifies an ocular problem common to persons at this client's developmental level, which is:

Presbyopia

A 3-year-old child with eczema of the face and arms has disregarded the nurse's warnings to "stop scratching, or else!" The nurse finds the toddler scratching so intensely that the arms are bleeding. The nurse then ties the toddler's arms to the crib sides, saying, "I'm going to teach you one way or another." How should the nurse's behavior be interpreted?

These actions can be construed as assault and battery

The nurse providing care for a client with a diagnosis of neutropenia reviews isolation procedures with the client's spouse. The nurse determines that the teaching was effective when the spouse states that protective environment isolation helps prevent the spread of infection:

To the client from outside sources

The client asks the nurse to recommend foods that might be included in a diet for diverticular disease. Which foods would be appropriate to include in the teaching plan? (Select all that apply.)

Whole grains Cooked fruit and vegetables Milk and eggs

A client with osteoporosis is encouraged to drink milk. The client refuses the milk, explaining that it causes gas and bloating. Which food should the nurse suggest that is rich in calcium and digested easily by clients who do not tolerate milk?

Yogurt