Exam 3 - foundations (engage fundamentals post tests)
a nurse is assessing a school-age child whose friend recently died. Which of the following findings should the nurse expect? A. the child believes that their friend's death is temporary B. the child clings to people C. the child holds back their feelings D. child thinks they are to blame for their friends death
C
a nurse is caring for a client that states, "my doctor said I ishould have an EMG. What is that?" which of the following responses should the nurse make? A. it is a test that determines if there is a loss of the ability to smell B. it is a test that measures the response of the eardrum to various sounds C. it is a test that determines if there is nerve damage affecting a muscle D. it is a test that is performed to diagnose damage to the retina of the eye
C
a nurse is caring for a client who has a deep foot wound with minimal exudate and necrotized tissue. for which of the following dressing types should the nurse anticipate a prescription to cover the wound? A. hydrofiber B. alginate C. hydrogel D. transparent film
C
a nurse is caring for a client who has a dime sized stage 1 pressure injury located on the sacrum. which of the following dressing types should the nurse use? A. hydrogel dressing B. wet gauze dressing C. transparent film D. alignate dressing
C
a nurse on a pediatric floor is teaching a newly licensed nurse about IV therapy. Which of the following information should the nurse include? A. perform range of motion exercises on the extremity containing the IV site B. shave the client's hair if the IV is placed on the scalp C. IV sites can be placed in the lower extremities up to the age of 2 years D. monitor the IV site, tubing, and connections every 4 hours
A
a nurse is assitsting with the are of a client following abdominal surgery. The nurse removes the client's surgical dressing and notes a separation of thewound edges. the nurse should identify that the client is experiencing which of the following complications? A. dehiscence B. evisceration C. hematoma D. fistula
A
a nurse is caring for a client who has a high phosphorus level. which of the following instructions regarding food should the nurse provide? A. you should eat white bread B. you can drink 2 cupos of milk per day C. you should limit broccoli to 3 cups/week D. you can have 4 servings of oatmeal per week
A
a nurse is caring for a client who is experiencing respiratory alkalosis. which of the following actions should be the goal of treatment for the client? A. increase the carbon dioxide level B. increase the respiratory rate C. increase th ebicarbonate level D. increase the pH level
A
a nurse is caring for a client who is receiving tube feedings via PEG. which ofthe following actions should the nurse implement in order to help prevent the cleint from aspirating? A. keep client's head elevated to at least 30 degrees for a minimum of 1 hour after a feeding B. verify the initial tube placement with an x-ray after the first feeding C. check the client's tube feeding tolerance every 12 hours D. check the pH of the gastric contents each day
A
a nurse is caring for a group of clients. which of the following clients should the nurse identify as having the highest risk for developing alterations in tissue integrity? A. a client who is incontinent and taking prescribed diuretic B. a client who has a lower extremity fracture and uses the overhead bed trapeze to move C. a client who is NPO for surgery and receiving IV fluids D. a client who has lung cancer and will be receiving their first radiation treatment
A
a nurse is caring for a middle adult client who asks about expected age-related changes, which of the following sensory changes should the nurse include as a n age related change? A. presbyopia B. diplopia C. myopia D. astigmatism
A
a nurse is discussing culturally competent care with another nurse. which of the following information should the nurse include? A. it is culturally insenstive to talk about impending death in some cultures B. most cultures agree with the use of opioids to treat pain C. a client's cultural information should be obtained from a coworker D. culture is irrelevant when a client is making a health care decision
A
a nurse is discussing hospice care services with the caregiver of a client who is terminally ill. which of the following information should the nurse include? A. nursing support will be provided in meeting the client's daily needs, including the admin of meds B. the caregiver can request their terminally ill loved one to be admitted to a professional care facility for a maximum of 2 days C. nurses are not allowed to become confidant to the caregiver D. nurse will have limited contact with the client and caregiver
A
a nurse is discussing the Dual Process Model of Grief with a newly licensed nurse. Which of the following statements shold the nurse make? A. a clients grief will oscillate between loss oriented grief and restoration-oriented grief B. during restoration-oriented grief, a client experiences intense feelings of guilt and sadness about the loved one's death C. a client is coping with secondary losses such as loss of income or housing during loss-oriented grief D. during loss oriented grief, a client focuses on rebuilding their future without their loved one
A
a nurse is discussing types of grief with a group of clients who have a serious illness. which of the following information should the nurse include? A. anticipatory grief occurs prior to the actual loss of someone or something B. normal grief lasts no more than 4 months after a loss has occured C. disenfranchised grief occurs when a client is unable to accept the death of a loved one D. prolonged grief is defined as the loss of a relationship that is considered socially unacceptable
A
a nurse is observing an AP care for a client. which of the following actions by the AP places client at risk for alterations in skin integrity? A. AP places client in high fowlers B. AP places pillows under client's lower extremities C. AP feeds client 80% of each meal D. AP cleans and dries the client's perineum after each episode of incontinence
A
a nurse is participating in a blood drive and is taking a donation from a client who has type O+ blood. the client asks the nurse what type of blood they can receive. Which of the following statements should the nurse make? A. you can receive a blood donation from donors with type O- and O+ blood B. you can receive a blood donation from donors with type B- and type A+ blood C. you can receive a blood donation from donors with type B- and type AB+ blood D. you can receive a blood donation from donors with type AB- and type A- blood
A
a nurse is preparing to perform a cranial nerve assessment on a client. which of the following actions should the nurse take to assess cranial nerve II? A. check the client's visual acuity using a snellen chart B. have client identify specific smells C. whisper in one of the cleint's ears while occluding the other D. observe for facial symmetry while the client smiles
A
a nurse is providing care for a client who has a sensory deficit. which of the following actions is the nurse's priority for the client? A. keep client's environment free from clutter B. offer opportunities for client to get exercise C. prevent client's social isolation D. provide nutritional education to the cleint
A
a nurse is reviewing a client's medical record and notes that their BMI is 25.5. how shoudl the nurse interpret this finding? A. the client is overweight B. the client is underweight C. the client's BMI is within normal range D. the client is obese
A
a nurse is reviewing discharge instructions with a client who has macular degeneration. which of the following information should the nurse include in the instructions? A. availability of aids to enhance vision B. antibiotic therapy C. risks associated wit hthe loss of peripheral vision D. treatment options
A
a nurse is assessing a client who is expecting disenfranchised grief. Which of the following findings should the nurse expect? A. social isolation B. verbalization of acceptance of the loss C. shares feelings of grief with others D. hypersomnia
A
A nurse is receiving report on four clients. the nurse should identify that which of the following clients might be exeriencing hypomagnesemia? A. a client who has vomited four times during the last 8 hours B. client who requested an extra breakfast tray to eat C. a client who can ambulate without assistance D. a client who reports extreme thirst
A
a charge nurse is observing a newly licensed nurse who is preparing to administer a blood transfusion to a client. for which of the following actions by the newly licensed nurse should the charge nurse intervene? A. the nurse selects 0.45% sodium chloride to use to prime the tubing B. the nurse asks another nurse to check the blood unit label and client identification prior to beginning the transfusion C. the nurse uses tubing with a filter for the blood transfusion D. the nurse discards the tubing after the first unit of blood is completed
A
a nurse is participating in a blood drive and is taking a donation from a client who has type A- blood. the client asks the nurse what blood types can receive their blood donation. Which of the following responses should the nurse make? (SATA) A+ B+ O+ AB- AB+ A-
A+, AB-, AB+, A-
a nurse is caring for an older adult client who is experiencing dehydration. The nurse should identify that which of the following factors increases the risk for dehydration in older adult clients? (SATA) A. decreased kidney function B. decreased thirst response C. decreased total body fluid D. eating watermelon daily E. eating cucumbers with each meal
A, B, C
a nurse is assessing a client who is experienceing digestive issues. which of the following findings should the nurse expect (SATA) A. nausea B. abdominal pain C. diarrhea D. reports of bloating E. reports of excessive salivation
A, B, C, D
a nurse is providing postmortem care for a client. which of the following actions should the nurse take? (SATA) A. document where body is being moved B. include name of anyone notified in medical record C. document date and time of death D. ensure cleint's belongings are accounted for E. place an identification tag on a minimum of one area of the client's body
A, B, C, D
a nurse is caring for a client who is prescribed a low glycemic index diet. the Client states, "I dont understand what this means." Which of the following responses should the nurse make? (SATA) A. the glycemic index of a food relates to its ability to increase the blood glucose level B. you should eat foods such as whole grains, fruits, and vegetables C. consuming white bread will increase your blood glucose level slowly D. try to limit or avoid potaties due to their high glycemic index E. foods with a high glycemic index will cause your blood glucose to increase rapidly
A, B, D, E
a nurse is caring for a client who is nearing the end of life. Which of the following responses by the nurse supports the client's dignity? (SATA) A. what would you like to know about your medications? B. I expect yyou will feel much better in a few days C. what can I do to help youfeel more independent? D. I think you should allow your family to make your health care decisions E. you must be getting tired of lying in bed
A, C
a nurse is caring for a client who is receiving treatment for hyponatremia. the nurse shoudl identify that which of the following findinds is an indication that the treatment has been effective? (SATA) A. the client states their muscle spasms are absent B. the client reports a headache C. the client denies being confused D. the client reports being nauseated E. the client reports feeling tired
A, C
a nurse is caring for a client whose provider prescribed a heart-healthy diet. which of the following information should the nurse include for the cleint regarding heart-healthy diets? (SATA) A. you should limit saturated fats in diet B. you should increase sodium intake to your taste C. eat foods with whole grains in your new diet D. its important to eat larger portions of fruits and veggies E. limiting high calorie food intake will promote adherence to your new diet F. continue to avoid skim milk and lean meats
A, C, D, E
a nurse is caring for a lcient who is actively dying. the client's caregiverasks the nurse about the client's noisy respirations. Which of the following should the nurse include? (SATA) A. they can be an indication of apporaching death B. deep suctioning is effective in removing trapped secretions C. turning the client's head to the side can assist with drainage D. medications can be administered to help dry up the secretions E. the client is unable to clear the secretions themselvs
A, C, D, E
a palliative care nurse is preparing an in srvice for newly hired staff members about common grief reactions. Which of the following info should the nurse include? (SATA) A. a client who is grieving often experiences a wide range of emotions B. the anniversary date of a loss should not trigger feelings of sadness after a client has fully accepted the loss C. a client may feel a sense of relief if the death of a loved one was expected D. a client may experience difficulty concentrating and hallucinations as a psychological response to loss E. behavioral responses to grief can include the refusal to eat or participate in social activities
A, C, D, E
a nurse is preparing to administer medications to a client. which of the following classifications of meds should the nurse identify as being ototoxic? (SATA) A. loop diuretics B. benzodiazepines C. NSAIDS D. antihistamines E. aminoglycoside antibiotics
A, C, E
a nurse is assessing a client who has delirium, which of the following manifestations should the nurse expect? (SATA) A. difficulty maintaining attention B. aphasia C. agitation D. alertness E. hallucination F. rambling speech
A, C, E, F
a nurse is teaching a client about hospice care. which of the following information should the nurse inclue? (SATA) A. you must have a terminal illness B. you are eligible for hospice care if you are expected to live for 12 months C. you can continute treatment to cure your illness D. you accept palliative care for comfort E. the health care provider must officially state that you are terminally ill
A, D, E
a nurse is reviewing a client's lab values. which of the following results should the nurse report to the provider? A. potassium 4.5 B. sodium 138 C. magnesium 3 D. calcium 10
c
a nurse is caring for a client who recently lost their job. Which of the following actions should the nurse take during the assessment step of the nursing process? (SATA) A. identify whether the client is experiencing feelings of grief B. avoid discussing the client's recent job to prevent upsetting the client C. check the client for physcial manifestations of grief D. ask the client about their support system E. provide education about the grief process to the client
A. C. D
a nurse is caring for a client who has sustained a gunshot wound to the abdomen and is 6 hr postoperative. the nurse notices protrusion of the client's organs from the incision site and calls for help. which of the following actions should the nurse take? A. ask the client to bear down and cough B. ask another nurse to bring icepacks to apply to the wound C. cover the cleint's wound with a sterile saline dressing D. place client in high fowlers position
C
a charge nurse is discussing Worden's four tasks of mourning with a newly licensed nurse. which of the following statements should the charge nurse include? A. "accepting the reality of the loss is the third task" B. "the pain of grief is experienced duringthe second task" C. "the client rearranges their life to live without their loved one during the fourth task" D. "during the third task, a client focuses on remaining connected to their loved one through positive memories"
B
a charge nurse is discussing hearing tests with a newly licensed nurse. which of the following information should the charge nurse include? A. the audiometer test measures the brain's electrical activity in response to sounds B. a tuning fork is placed against the clients mastoid bone during the Rinne test C. the otoacoustic stimulation test is the most commonly performed hearing test D. small electrodes are placed behind the client's ears during an electromyography test
B
a charge nurse is preparing an in-service for staff members about spiritual influences on grief. Which of the following information should the nurse include? A. many religions reject the idea of reincarnation after death B. religion can provide comfort during the grieving process C. sensitivity to religious beliefs is not a priority in the delivery of client centered care D. spirituality and religious beliefs can hinder post bereavement outcomes
B
a hospice nurse is caring for a client who is hallucinating and talking to someone who is not there. which of the following actions should the nurse take? A. tell the clinet that there is no one there B. ensure client safety and prevent injury C. decrease verbal interactions with the client D. reorient the client to reality
B
a nurse in an outpatient clinic is assessing the incision site of a client who is 7 day postop. which of the following findings should the nurse expect? A. a red incision site with a small amount of exudate B. a bright pink incision site that is absent of exudate C. a pale pink incision site with moderate amounts of exudate D. white to silver incision site absent of exudate
B
a nurse is assessing a client who is exhibiting signs of a fluid and electrolyte imbalance. which of the following findings should the nurse identify as a potential cause for the client's fluid and electrolyte imbalance? A. the client reports working in a warehouse in 70 degree temperature B. the client reports that they performed yard work for 8 hours in 95 degree temp earlier that day C. the client reports that their provider decreased their diuretic dose D. the client reports they had a 24 hour intestinal virus 2 weeks ago
B
a nurse is assessing a client's hair and notes that it is brittle. which of the following should the nurse determine about the client's nutritional intake? A. the client is not getting enough vitamin A B. the client has insufficient protein in their diet C. the client needs more vitamin D from sun exposure D. the client needs to eat five servings of fruits and veggies daily
B
a nurse is caring fo a client who is actively dying. the client's caregivers state they are interested in donating the client's organs. Which of the following actions should the nurse take? A. discuss the process of organ donation with the caregiver B. make a referral to an organ procurement organization C. inform the caregiver that only the client can give authorization for organ donation D. notify the health care provider since they are responsible for discussing organ donation with the family member
B
a nurse is caring for a client who has a peripherally inserted central catheter. for which of the following comlications should the nurse monitor? A. the need for multiple IV sticks B. infection at the access site C. dehydration D. infiltration
B
a nurse is caring for a client who has a terminal illness and reports feeling isolated from family and freinds. which of the following actions should the nurse take? A. limit visitors to one or two people B. assist in scheduing friends and family to visit C. discourage face-to-face visits for the client D. instruct the client to limit their use of online support groups
B
a nurse is caring for a client who has an acid-base imbalance and is experiencing hypoxia. which of the following actions should the nurse take first? A. initiate continuous cardiac monitoring B. elevate the head of the client's bed C. instruct the client to deep breathe and cough D. initiate continuous SpO2 monitoring
B
a nurse is caring for a client who is schedulted for an otoacoustic emissions test. the client asks what to expect during the test, which of the following responses should the nurse make? A. you will have small electrodes placed on your scalp during the test B. you will have small probe place in your ear canal during the test C. you will have dye injected through an IV during the test D. you will have photographs taken using a special camera during the test
B
a nurse is caring for an adult client who is mourning the death of a sibling. which of the following information should the nurse consider when caring for the client? A. older adult clients tend to experience fewer losses of loved ones B. grief differs for adults due to their full understandign of death and memories of the deceased C. adults usually do not report physicial manifestations associated with experiencing grief D. experiencing bereavement is not as common in adults when compared to clients in other age groups
B
a nurse is discussing palliative care with a client who has colon cancer. Which of the following information should the nurse include? A. palliative care is limited to a psecific time frame B. palliative care uses a holistic approach C. palliative care is provided after a client has stopped curative treatment methods D. palliative care is offered to clients who have non-life-threatening illnesses
B
a nurse is helping a client calculate how many net carbs they consume in their last meal. the client's food had a total of 72 g of carbs and 9g aof fiber. how many net carbs did the client consume? A. 81 B. 63 C. 8 D. 72
B
a nurse is monitoring a client following a cholecystectomy. which of the following findings should the nurse identify as a potential manifestation of sepsis? A. hypertension B. increased blood glucose C. decreased WBC count D. increased BUN
B
a nurse is planning care for an older adult client who is bedridden. which of the following actions should the nurse include in the plan to prevent skin breakdown? A. firmly massage lotion into the cleinit's skin B. tilt the client on their side at 30 degree C. slide the client to the edge of the bed to transfer D. keep the head of the bed at 45 degrees when in the supine position
B
a nurse is preparing to obtain a wound culture from a client who has a suspected wound infection. which of the following actions should the nurse take? A. obtain the culture using a clean cotton applicator B. clean the wound with 0.9% sodium chloride C. collect drainage from the area surrounding the wound D. place the applicator in a dry vial until cultures are complete
B
a nurse is reviewing laboratory results for a client and notes the following arterial blood gas values: pH 7.31. PaCO2 49 mmHg, and HCO3- 25 mEq/L. the nurse shoudl interpret these findings as an indication of which of the following acid-base imbalances? A. metabolic acidosis B. respiratory acidosis C. metabolic alkalosis D. respiratory alkalosis
B
a nurse is reviewing prescriptions for a client who needs IV fluid replacement therapy due to vomiting and diarrhea. Which of the following fluid prescriptions should the nurse expect to initiat? A. 3% sodium chloride B. 0.9% sodium chloride C. 0.45% sodium chloride D. dextrose 10% in water
B
a nurse is reviewing the process of how a refraction assessment is performed with a client. which of the following statemtns should the nurse make? A. this test is performed using snellen chart B. this test is performed using elense of various prescription strength C. this test is performed by injecting dye into a vein D. this test is performed by measuring the amount of pressure inside the eyes
B
a nurse is teachign a client who has a pressure injury on their leg about proper nutrition to facilitate wound healing. which of the following client statements indicates an understanding of the teaching? A. I should consume a diet high in carbs B. I should increase my protein intake C. I should include fruits and veggies with every meal D. I should avoid meat products
B
a nurse is teaching a newly licensed nurse about wound healing by secondary intention. which of the following statements by the newly licensed nurse indicates an understanding of healing by secondary intention? A. this type of healing carries a lower risk of infection than others B. this type of healing begins in the wound bed with the generation of granulation tissue C. these wounds heal faster than those that heal by other processes D. these wounds require a dry wound bed in order for healing to occur
B
a nurse learns that a coworker has died unexpectedly. Which of the following actions should the nurse take? A. keep personal feelings of grief to themselves B. recognize their feelings of grief C. attempt to ignore physical manifestations of grief D. avoid family and friends when feeling deep sadness
B
a charge nurse is reviewing Kubler-Ross's five stages of grief with a newly licensed nurse. which of the following should the nurse make? (SATA) A. the five stages occur in a specific order for every client B. clients might not go through all five stages of grief C. clients can return to a stage of grief after moving into one of the other stages D. Clients who are grieving might attempt to bargain with a higher power E. the stages of grief are only experienced by clients who have a terminal diagnosis
B, C, D
a nurse is caring for a client who has renal disease and must limit potassium intake. which of the following foods should the nurse instruct the client to avoid because they are high in potassium (SATA) A. apples B. bananas C. dried beans D. spinach E. tomatoes
B, C, D, E
a nurse is caring for a client whose spouse recently died. the client is from a different culture than the nurse. Which of the following information should the nurse consider when caring for the client? (SATA) A. rituals used to cope with loss are universal across every culture B. cultural based rituals can assist clients in handling the death of a loved one C. culture may determine how a client expresses their grief D. cultural practices do not dictate the expected length of mourning E. rituals regarding death direct what procedures are performed on the body after death
B, C, E
a nurse is caring for an older adult client who reports unintended weight loss. the client reports that their food does not taste right. The nurse should inform the client that ability to taste which of the follwoing can decrease with age? (SATA) A. sweet B. sour C. spicy D. bitter E. salty F. savory
B, D, E
a nurse is caring for a client who has the following arterial blood gas values: pH 7.44, PaCO2 37 mmHg, and HCO3- 24 mEq/L. The nurse should identify that these values are an indication of which of the following? A. metabolic acidosis B respiratory acidosis C. acid-base balance D. respiratory alkalosis
C
a nurse is caring for a client who states, "I feel like I dont have to eat a varied diet when I take my multivitamin" which of the following repsonses should the nurse make? A. if taken 4+ days/week, a multivitamin provides all the nutritents you need B. as long as you take a multivitamin daily, you do not need to eat a varied diet each day C. a multivitamin should not be used in place of a nutritious diet D. as long as the multivitamin isnt generic, it can replace unhealthy dietary choices
C
A nurse is caring for a client who requires a replacement peripheral IV. the client is dehydrated and requires a smaller gauge catheter than the #20 gauge being replaced. which of the following gauge catheters should the nurse plan to use? A. 16 gauge B. 18 gauge C. 22 gauge D. 14 gauge
C
A nurse is planning care for a client who is terminally ill and speaks a different language than the nurse. Which of the following actions should the nurse take? A. use a family member as a translator B. allow an assistive personnel to translate for the client C. use the health care facilitiy's interpreter services D. download a smartphone application from the internet
C
a nurse is caring for a client who has a new prescription for a clear liquid diet. the client asks the nurse, "how long will I have to be on this type of diet?" which of the following repsonses should the nurse make? A. you will be on this diet as long as the provider feels you need to be B. you might be on this diet fora week or two C. you should not be on this diet for more than a few days D. you should speak with the provider about your concern
C
a nurse is caring for a client who has a new prescription for parenteral nutrition. the client states, "I am scared that I will be on this therapy for the rest of my life" Which of the following responses should the nurse make? A. There is a good chance you will have to be on this therapy for the rest of your life. B. parenteral nutrition is very common and should not interfere with your daily activities C. this type of nutrition can be lifelong, but it can also be temporary depending on how your nutritional needs change D. I am sure you will need parenteral nutrition temporarily
C
a nurse is caring for a client who has a portable wound bulb suction device and notes that the drainage bubble is three fourths full. which of the following actions should the nurse take? A. decrease the drainage suction force B. place the bulb on a flat surface and measure the amount of drainage C. empty and measure the drainage D. kink the tubing to prevent further drainage
C
a nurse is caring for a client who has a prescription to receive one unit of packed red blood cells. the client blood type is AB+ and the nurse receives a unit of A- blood from the blood bank. which of the following actions should the nurse take? A. return the blood unit as it is not compatible with the client's blood type B. stay with the client for 15 min prior to starting the blood transfusion C. verify the unit of blood with another nurse D. prime the blood tubing with 0.45% sodium chloride
C
a nurse is caring for a client who has heart failure and a prescription to receive a unit of packed red blood cells. the nurse should plan to infuse blood over which of the following lengths of time? A. 1 hour B. 2 hours C. 4 hours D. 6 hours
C
a nurse is caring for a client whose partner recently died. In which step of the nursing process should the nurse and client identify the goals for the client's care? A. implementation B. evaluation C. planning D. analysis
C
a nurse is caring for a nondiabetic client who has a new prescription for a fasting blood glucose check. the nurse checks the client's blood glucose and it is 67 mg/dL. which of the following actions should the nurse take next? A. document the client's blood glucose level B. report the client's blood glucose level to the provider C. provide the client with a 15g carb snack D. recheck the blood sugar in 15 mins
C
a nurse is caring fora client who is actively dying. which of the following actions should the nurse take for alterations in breathing pattern? A. withhold opiods because they can hasten the client's death B. report changes inthe respiratory pattern to the health care provider as they occur C. educate the family about the expected respiratory changes D. inform the family that oxygen therapy has no benefit
C
a nurse is preparing an in service for a group of staff members about types of tests used to diagnose sensory impairments. which of the following information should the nurse include? A. an electromyography test is performed by placing small electrodes on the scalp B. a fluorescein angiography test diagnoses dysfunction of the cochlea C. a bone oscillator test measures how efficiently sound waves are transmitted through the ossicles D. an amsler grid test is performed by looking at the internal eye using a slit lamp
C
a nurse is preparing for an initial visit with a client who is experiencing grief. Which of the following tasks should the nurse plan to complete first? A. provide info to the client about stages of grief B. encourage the client to share thoughts about their loss C. develop a relationship with the client D. ask client if they are experiencing physical manifestations of grief
C
a nurse is providing discharge teaching to the caregiver for a client who has a. stage 1 pressure injury to the sacrum. Which of the following instructions should be included to the caregiver to prevent further skin breakdown? A. be sure to keep the skin moist B. do not use pillows to support extremities C. flex the client's knees while in bed D. provide a firm mattress for the client
C
a nurse is reviewing hospice care servises with a group of newly hire nurses. Which of the following should the nurse include? A. hospice servises are terminated with the death of the client B. hospice services are limited to serving the client C. hospice care is an interdisciplinary team effort D. hospice care volunteer services are limited to direct client care
C
a nurse is reviewing the arterial blood gas values for a client and notes the following results: pH 7.49, PaCO2 39mmHg, and HCO3- 35 mEq/L. the nurse should interpret this ABG reading as an indication of which of the follwoing acid-base imbalances. A. metabolic acidosis B. respiratory acidosis C. metabolic alkalosis D. respiratory alkalosis
C
a nurses is assessing a client for hearing loss. which of the following findings should the nurse identify as an indication of a possible hearing loss? (SATA) A. speaks in soft tones B. reports ringing in the ears C. asks for questions to be repeated D. withdraws from social activities E. reports feeling dizzy at times F. describes sounds as being muffled
C, D, F
a nurse caring for a client who is experiencing hypovolemia. Which of the following findings should the nurse identify as the priority to report to the provider? A. dry mucous membranes B. decreased urine output C. report of thirst D. decrease in level of consciousness
D
a nurse has completed assessing and analyzing data fora client who has an acid-base imbalance. which of the following steps of the nursing process should the nurse take next? A. implementation B. reassessment C. evaluation D. planning
D
a nurse is reviewing the medical record of a client who reports recent anosmia. the nurse shoudl identify which of the following conditions as a risk factor for developing anosmia? A. gastroesophageal reflux disease B. herniated lumbar disc C. wernicke's aphasia D. alzheimer's disease
D
a nurse in a dermatology clinic is developing a skin anatomy poster to display for clients. which of the following information should the nurse plan to include on the poster? A. the epidermis contains cells that assist in systemic immune responses B. collagen and elastin fibers increase with age C. the skin consists of four distinct layers D. the dermis contains blood vessels that help nourish the epidermis
D
a nurse is assessing a 16 year old client whose parent recently died. Which of the following findings should the nurse expect? A. the client is still developing an understanding of death B. the client feels that "everyone understands me" C. the client can easily express their emotions D. the client displays high-risk behaviors
D
a nurse is assessing a cleint whose family is concerned that the client has developed dementia, which of the following findings should the nurse identify as a manifestation of dementia? A. rapid onset memory loss B. hyperglycemia C. hypervigilance D. difficulty problem solving
D
a nurse is assessing a client who has been receiving IV therapy for several days and notes that the client's daily weight has increased. the nurse should identify that the client is at risk for develooping which of the following IV-related complications? A. phlebitis B. extravasation C. air embolism D. circulatory overload
D
a nurse is assessing a client who is getting divorced and reports feelings of loss associated with no longer being in the role of a spouse. the nurse should identify that the loss of a previously held role is which of the following types of losses? A. loss of autonomy B. loss of dreams and expectations C. loss of safety D. loss of identity
D
a nurse is caring for a client who is actively dying and notes the client's feet are purple and marbled. which of the following findings should the nurse expect? A. the client's feet are warm to the touch B. the client feels pain in affected extremity C. the client hasa fever D. mottling is visible on the clients legs
D
a nurse is caring for a client who reports decreased peripheral vision. The nurse should identify this as a manifestation of which of the following visual impairments? A. diabetic retinopathy B. macular degeneration C. cataract D. glaucoma
D
a nurse is caring for a client who states, "I have been getting a lot of cavities lately, but I dont know what is causing them." which of the following responses should the nurse make? A. a lack of protein can cause a problem with cavities B. cavities can be caused by a diet low in vitamin C C. increasing your consumption of leafy green vegetables and tomatoes can help with this. D. drinking sugary beverages can make you prone cavities
D
a nurse is caring for a client who states, "I only eat a diet high in protein and carbs" which of the following responses should the nurse make? A. make sure to get enough servings of red meat in your daily diet B. your diet is varied but should also be high in calorie intake C. a varied diet should be high in protein and carb consumption D. a nutritious diet should include carbs, protein, fiber, and healthy fats
D
a nurse is caring for a client who was recently diagnosed with chronic kidney disease. The client asks the nurse, "Why me? this is not fair." the nurse should identify the client's statement as an expression of which of the following stages of grief? A. Denial B. depression C. bargaining D. Anger
D
a nurse is caring fora client who is actively dying and is discusing pain management with the client's caregiver. Which of the following information should the nurse include? A. pain control begins with the use of opioids B. the use of nonpharmacological interventions is contraindicated C. the use of pain medications can prolong the client's death D. a combination of apporaches is suggested to manage pain symptoms
D
a nurse is discussing the benefits of palliative care with a newly licensed nurse. Which of the following information should the nurse include? A. palliative care is offered to clients whose cancer has been in remission for 5 years B. palliative care will increase the client's time spent in the health care facility C. palliative care reduces cleint satisfaction D. palliative care imporves the client's quality of life
D
a nurse is discussing the concept of spirituality with a newly licensed nurse. which of the following information should the nurse include? A. spirituality can be easily defined B. spirituality is similar for all clients C. religion and spirituality is interchangeable D. spirituality focues on the significance and purpose of life
D
a nurse is preparing to assist with feeding a client who is at risk for aspiration. which of the following actions should the nurse take? A. position the client upright at a 45 degree angle B. turn on the television per the client's request C. avoid allowing the client to drink until meal is finished. D. cut the clients food into small bites
D
a nurse is preparing to perform a cranial nerve assessment on a cleint. which of the following actions should the nurse take to assess cranial nerve VIII? A. monitor for symmetry when client shrugs shoulders B. as the cleint to identify a smell in each nostril C. have the cleint stick out their tongu D. whisper something in one ear while occluding the other ear
D
a nurse is preparing to start an IV for a client at high risk for bleeding. which of the following actions should the nurse take? A. apply a cold compress to the selected IV site B. ask the client to hold the extremity up prior to searching for an IV site C. ask the client to spread the fingers of the selected extremity D. apply a blood pressure cuff set to 30 mmHg
D
a nurse is providing teaching for a client who has a prescription for an alginate dressing for a wound. which of the following statements by the client indicates an understanding of an alginate dressing? A. the dressing will need to be changed every 24 hours B. this type of dressing is used in small wounds with small amounts of drainage C. this dressing may develop a foul smelling, yellow, gelatinous film on its underside as bacteria are trapped D. this type of dressing will need a secondary dressing for reinforcement
D
a nurse is reviewing a client's latest arterial blood gas report. which of the following values should the nurse identify as the priority to report to the provider? A. pH 7.37 B. PaCO2 43 mmHg C. HCO3 27 mEq/L D. PaO2 76 mmHg
D
a nurse is teaching an assistive personnel about the skin of older adults. which of the following statements by the AP indicates of the teaching? A. skin changes cause the synthesis of vitamin B to decrease with age B. The layers of the skin become detached with age C. older adult clients have more moisture in the skin, placing them at risk for maceration. D. the skin of older adults is thinner and has less subcutaneous padding over bony prominences
D
a nurse is using the NURSE mnemonic while speaking with a client who is experiencing grief. Which of the following responses by the nurse demonstrate the concept represented by the U in NURSE mnemonic? A. "What is the most challenging aspect for you at the time?" B. "I am going to be here for you all night" C. "It sounds like you may be feeling overwhelmed" D. "there is a lot going on right now, how can I be of help to you?"
D
a nurse is caring for a clinet who has a terminal illness and states they want to experience a "good death". Which of the following actions should the nurse take? A. determine the client's definition of a "good death" B. inform the client that culture is irrelevant to an individual's perception of a "good death" C. inform the client that a "good death" is not possible D. communicate with the client tha tcaregivers are prevented from providing a "good death" for the client
a
a nurse is caring for a client who reports having daily constipation. which of the following information should the nurse provide to the client regarding fiber intake? (SATA) A. increasing daily fiber intake can help alleviate the issue of consitpation B. eating more whole grains can promote regular bowl movements C. consume 10g of fibers per day D. foods such as white rice increase fiber intake E. decreasing daily fiber intake can help alleviate digestive discomfort
a, B
a nurse is grieving following the death of a client who had a terminal illness and is having difficulty sleeping and concentrating. which of the following actions should the nurse take? A. avoid talking with more experienced nurses about coping with the death of a client B. refrain from attending the client's funeral C. participate in an exercise program D. distance themselves from the client's family
c
