Final Exam
Which postural deformity might be assessed in a teenager? Kyphosis Rickets Osteoporosis Scoliosis
Scoliosis
A client with an upper respiratory infection (common cold) tells the nurse, "I am so angry because the nurse practitioner would not give me any antibiotics." What would be the most appropriate response by the nurse? "Antibiotics have no effect on viruses." "Let me talk to the physician and see what we can do." "Why do you think you need an antibiotic?" "I know what you mean; you need an antibiotic."
"Antibiotics have no effect on viruses." viruses are the smallest of all microorganisms. Viruses, including the common cold and AIDS, cause many infections. Antibiotics have no effect on viruses. The best response to the client is to teach about the virus and how antibiotics are ineffective against viruses.
The home health nurse is placing a client in the Fowler's position in an adjustable bed in the client's home. What information should the nurse teach the family about the Fowler's position? "Use at least two big pillows to support the client's head." "Cross the client's arms over the abdomen when moving the client." "Avoid bending the mattress at the knee level." "Keep the hands lower than the rest of the body."
"Avoid bending the mattress at the knee level."
A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's statements would appear at the beginning of a charting entry? "Client is reporting that her abdominal pain is rated at 8/10." "Client is guarding her abdomen and occasionally moaning." "Client has a history of recent abdominal pain." "2 mg hydromorphone hydrochloride PO was administered with good effect."
"Client is reporting that her abdominal pain is rated at 8/10."
The nurse has completed an assessment of a client's typical hygiene practices. How should the nurse best document the findings of this assessment in the client's chart? "Client normally bathes and washes her hair every other day; applies moisturizer to dry areas on her elbows and forearms." "Client prioritizes personal hygiene in her daily routines and is proactive with skin care." "Client bathes more often than necessary and consequently experiences dry skin." "Client's level of personal hygiene is acceptable and age-appropriate."
"Client normally bathes and washes her hair every other day; applies moisturizer to dry areas on her elbows and forearms."
The nurse observes slight bruising on the client's left thigh during a bed bath and palpates a lump on the anterior surface of the thigh. Which will the nurse document on the electronic health record (EHR)? "During bed bath, slight bruising noted on left thigh. 5 cm hard lump palpated on anterior surface of the thigh." "Bed bath completed." "Client has bruising on left thigh from previous fall." "During bed bath, nurse palpated 5-cm lump on client's left thigh."
"During bed bath, slight bruising noted on left thigh. 5 cm hard lump palpated on anterior surface of the thigh."
Which data entry follows the recommended guidelines for documenting data? "Client is overwhelmed by the diagnosis of pancreatic cancer." "Client's kidneys are producing sufficient amount of measured urine." "Following oxygen administration, vital signs returned to baseline." "Client complained about the quality of the nursing care provided on previous shift."
"Following oxygen administration, vital signs returned to baseline."
A nurse is conducting a health history for a client with a chronic respiratory problem. What question might the nurse ask to assess for orthopnea? "Do you have problems breathing when you walk up stairs?" "Does your medication help you breathe better?" "How many pillows do you sleep on at night to breathe better?" "Tell me about your breathing difficulties since you stopped smoking."
"How many pillows do you sleep on at night to breathe better?" People with difficulty breathing can often breathe more easily in an upright position, a condition known as orthopnea. While the client is sitting or standing, gravity lowers organs in the abdominal cavity away from the diaphragm, giving more room for the lungs to expand. People with orthopnea characteristically use many pillows during sleep to accomplish this.
The nurse conducting an in-service on hand hygiene determines that additional education is needed when a participant states: "I do not need to wash my hands if I am using gloves." "I will wash my hands before touching a client." "I can wash my hands before a clean procedure." "If I am able, I will wash my hands after touching the client's surroundings."
"I do not need to wash my hands if I am using gloves."
Which statement indicates that a plan to assist a client in developing and following an exercise program has been effective? "I have just been too busy to do my daily exercises." "I guess I will begin the activity we discussed next week." "I know I should exercise, but my health is not very good." "I have lost 10 pounds (4.5 kg) because I walk 2 miles (3.2 km) every day."
"I have lost 10 pounds (4.5 kg) because I walk 2 miles (3.2 km) every day."
A client is scheduled to be fitted with a prosthesis following the loss of the nondominant hand after a traumatic injury. Nurses have documented an outcome that states, "After attending multiple educational sessions, the client will demonstrate correct technique for applying the prosthesis." Which statement by the client would indicate a need to revise the plan of care related to this outcome? "I'm not interested in wearing an artificial hand." "People are going to look at me when I wear this thing." "This doesn't look like my other hand." "I don't understand the technology that's used in this artificial hand."
"I'm not interested in wearing an artificial hand."
A nurse manager is talking with a new nurse. The nurse manager determines that the new nurse is thinking critically based on which statement? "I'm not sure what to do here?" "I don't know if the client understands." "If I give this medication, the client probably will be sleepy." "If my client gets short of breath, I'm unclear about why."
"If I give this medication, the client probably will be sleepy."
The nurse is teaching a newly diagnosed hypertensive client how to take his or her own BP at home. The client asks why it is so important to do this. What is the nurse's best response? "Because it is required by your insurance." "Monitoring your BP at home will assist in controlling your BP, thereby decreasing your risk for heart attack and stroke." "Your BP measurements at home are more accurate than the ones we do in the health care setting." "You must do this because the doctor ordered it."
"Monitoring your BP at home will assist in controlling your BP, thereby decreasing your risk for heart attack and stroke."
Which question would be most helpful to the nurse in facilitating critical thinking during outcome identification and planning? "How do I best cluster these data and cues to identify problems?" "What problems require my immediate attention or that of the team?" "What major defining characteristics are present for a nursing diagnosis?" "How do I document care accurately and legally?"
"What problems require my immediate attention or that of the team?"
A client has a nasogastric tube following abdominal surgery. Which intervention(s) does the nurse perform to prevent an alteration in the client's oral health? Select all that apply. Apply lubricant to the lips and nostrils Offer water to rinse the mouth every hour Encourage the client to swallow saliva naturally Assist the client to brush teeth at least every 4 hours Swab oral mucosa with lemon-glycerin swabs as needed.
-Apply lubricant to the lips and nostrils -Offer water to rinse the mouth every hour -Encourage the client to swallow saliva naturally -Assist the client to brush teeth at least every 4 hours
While assessing for orthostatic hypotension, the nurse follows which step(s) when taking the blood pressure? Select all that apply. Check and record blood pressure taken while the client is in the bed. If the client feels dizzy when standing, have the client sit on the side of the bed. Assist client to standing position and wait 2 to 3 minutes before taking blood pressure. Record measurements and note if the drop is ≥20 mm Hg systolic and ≥10 mm Hg diastolic. Use the same blood pressure cuff the whole time.
-Check and record blood pressure taken while the client is in the bed. -Assist client to standing position and wait 2 to 3 minutes before taking blood pressure. - recording measurements and note if the drop is ≥20 mm Hg systolic and ≥10 mm Hg diastolic. -Use the same blood pressure cuff the whole time.
The nurse reviews principles of infection prevention during yearly safety training. Which action(s) would the nurse use as an example of safe practice? Select all that apply. Recapping of needles immediately after use Donning gloves and gowns as a substitute for handwashing in some circumstances Applying alcohol-based products to reduce risk of contracting Clostridium difficile Sterilizing any item entering the vascular system Wearing artificial nails at an acceptable length in most areas of the clinic
-Donning gloves and gowns as a substitute for -handwashing in some circumstances -Sterilizing any item entering the vascular system
The nurse is caring for a client with human immunodeficiency virus (HIV) who currently has no signs or symptoms of the disease. Which important information about being an HIV carrier does the nurse teach the client? -HIV can be transmitted through the secretions of an infected person who is coughing, sneezing, or talking. -HIV can be transmitted through body surface-to-body surface contact between an infected person and another person. -HIV can be transmitted from an infected person to another person through blood, semen, vaginal fluids and breast milk. -HIV cannot be transmitted from an infected person to another person unless symptoms of the disease are present.
-HIV can be transmitted from an infected person to another person through blood, semen, vaginal fluids and breast milk.
A nurse provides care for an adolescent who is diagnosed with mononucleosis. Which crucial information does the nurse include in client education about the condition? Select all that apply. It is important to practice safe sex because a form of mononucleosis can be transmitted through sexual contact. Mononucleosis is called the "kissing disease" so refrain from kissing. Because mononucleosis is spread through saliva, do not share food, drinks, or silverware. Cover coughs or sneezes to reduce the risk of spreading infection. The Epstein-Barr virus (EBV) causes mononucleosis.
-It is important to practice safe sex because a form of mononucleosis can be transmitted through sexual contact. -Mononucleosis is called the "kissing disease" so refrain from kissing. -Because mononucleosis is spread through saliva, do not share food, drinks, or silverware. -Cover coughs or sneezes to reduce the risk of spreading infection. -The Epstein-Barr virus (EBV) causes mononucleosis.
A nurse is preparing to perform oral care for a client who has full dentures. Which action(s) should the nurse take? Select all that apply. Provide privacy while the client removes dentures from the mouth. Use a toothbrush and paste to gently brush all surfaces. Rinse the dentures with water or normal saline if the client is dehydrated. After cleaning, insert the lower denture followed by the upper denture. Use a sterile 4 × 4 in (10 × 10 cm) gauze to remove debris from the gums and mucous membranes. Place paper towels or a washcloth in the sink to prevent damage if the dentures are dropped during cleaning.
-Provide privacy while the client removes dentures from the mouth. -Use a toothbrush and paste to gently brush all surfaces. -Rinse the dentures with water or normal saline if the client is dehydrated. -Place paper towels or a washcloth in the sink to prevent damage if the dentures are dropped during cleaning.
A nurse is changing the dressings of a client in the burn unit. Which action(s) should the nurse perform to maintain asepsis and client comfort? Select all that apply. Wash hands thoroughly and then don sterile gloves. Utilize isolation precautions including donning gloves, gowns, and face mask. Ensure family visitors know they cannot bring flowers or fresh fruit to the client. Keep nails short with no polish. Practice good personal hygiene including showering before each shift.
-Wash hands thoroughly and then don sterile gloves. -Utilize isolation precautions including donning gloves, gowns, and face mask. -Ensure family visitors know they cannot bring flowers or fresh fruit to the client. -Keep nails short with no polish. -Practice good personal hygiene including showering before each shift.
The nurse is monitoring a student who is performing surgical hand asepsis. Which student actions indicate the need for further education from the nurse? Select all that apply. -wearing a gold wedding band -washing the nails and all surfaces of each finger -using at least five strokes for cleansing in each area -dropping hands to side when the wash is complete -dropping the soapy sponge in the sink to discard -cleaning beneath each fingernail with a file
-wearing a gold wedding band -using at least five strokes for cleansing in each area -dropping hands to side when the wash is complete
The nurse is creating a concept map to plan for the care of a client. Place in order the steps the nurse will perform to create the concept map. Collect client problems and concerns on a list. Connect and analyze the relationships. Create a diagram. Keep in mind key concepts. Apply the concept map to client care.
1.Collect client problems and concerns on a list. 2.Connect and analyze the relationships. 3.Create a diagram. 4.Keep in mind key concepts. 5.Apply the concept map to client care.
Put the steps of the clinical reasoning cycle in the correct order. Review current information. Analyze data to come to an understanding of signs or symptoms. Match current clients to past clients. Describe what the nurse wants to happen, a desired outcome, a time frame. Select a course of action between different alternatives available. Evaluate the effectiveness of actions.
1Review current information. 2Analyze data to come to an understanding of signs or symptoms. 3.Match current clients to past clients. 4.Describe what the nurse wants to happen, a desired outcome, a time frame. 5.Select a course of action between different alternatives available. 6.Evaluate the effectiveness of actions.
The nurse prepares to give the change-of-shift report. The nurse provides the oncoming nurse with the intake and output record of the client for the shift, pictured above. What is the client's fluid balance in milliliters? Record your answer using a whole number.
485
Over the course of a day, a nurse encounters many different clients whose pulse rates she must measure. For which clients should she measure the apical pulse? Select all that apply. A client who is on a medication that has dysrhythmia as a side effect A healthy 8-year-old girl An older adult client, whose pulse when measured peripherally is found to be extremely rapid A young, athletic man whose resting heart rate tends to be lower than normal A middle-aged woman who has a fever A young woman who is pregnant
A client who is on a medication that has dysrhythmia as a side effect A healthy 8-year-old girl An older adult client, whose pulse when measured peripherally is found to be extremely rapid
A nurse is assessing the activity level of an infant age 5 months. What normal findings would be assessed? Ability to sit; head control Ability to pick up small objects Progress toward running and jumping Progress toward unassisted walking
Ability to sit; head control
The nurse is caring for a client following major surgery. Which intervention helps to prevent orthostatic hypotension in the postsurgical client? Assist the client out of bed upon rising. Administer prophylactic antibiotics as prescribed. Administer intravenous fluids per the health care provider's prescription. Allow family members to assist the client during ambulation.
Administer intravenous fluids per the health care provider's prescription.
A client comes to the emergency department reporting severe chest pain. The nurse asks the client questions and takes vital signs. Which step of the nursing process is the nurse demonstrating? Assessing Diagnosing Planning Implementing
Assessing
When should the nurse initiate discharge planning for a client in an acute health care setting? At discharge At admission Before admission After discharge
At admission
Which guidelines should the nurse consider when writing outcomes? Select all that apply. The nurse should derive each set of outcomes from a combination of nursing diagnoses. At least one of the outcomes the nurse writes should show a direct resolution of the problem statement in the nursing diagnosis. The nurse should not be concerned if the client and family do not value the outcomes as long as they support the plan of care. The nurse should write outcomes that are brief and specific and support the overall plan of care. The outcomes the nurse writes need not be supportive of the total treatment plan as long as they specify a goal. The nurse may write outcomes that do not specify a timeline as long as they are linked with other outcomes.
At least one of the outcomes the nurse writes should show a direct resolution of the problem statement in the nursing diagnosis. The nurse should write outcomes that are brief and specific and support the overall plan of care.
What is the primary purpose of the client record? Communication Advocacy Research Education
Communication
A nurse is planning hygiene for a client with dementia. The nurse understands the need to provide an environment that will aid her in the care of this client. Which action will she perform? Ask several staff to be in the room for safety since the client is sometimes agitated. Create a calming environment with little stimuli. Refuse to bathe the client because the nurse and client have not established a rapport. Delegate this task to someone else since it's not the nurse's responsibility to perform hygiene for clients.
Create a calming environment with little stimuli.
The nurse is providing oral care to a hospitalized client. Which outcome of this intervention is the priority? Decreasing the incidence of hospital-acquired pneumonia Promoting the client's sense of well-being Preventing dental caries Preventing deterioration of the oral cavity
Decreasing the incidence of hospital-acquired pneumonia
A nurse is providing oral care to a client with dentures. What action would the nurse perform first? Assess the mouth and gums. Don gloves. Wash the client's face. Apply lubricant.
Don gloves.
A nurse administers medications to a client. Which step of the nursing process would the nurse perform next? Assessing Diagnosing Evaluating Planning
Evaluating
A client expresses concern that there is an increase in urine output after exercising. How would the nurse address the client's concern? Select all that apply. Explain that urination after exercise is a result of increased circulation to the kidneys and is a normal function Assess cardiovascular function and blood pressure Ask the client to provide details of the exercise regimen including frequency and type Perform a 24-hour input and output assessment Evaluate for diabetes mellitus
Explain that urination after exercise is a result of increased circulation to the kidneys and is a normal function Assess cardiovascular function and blood pressure Ask the client to provide details of the exercise regimen including frequency and type Evaluate for diabetes mellitus
Which is a common error nurses make when writing client outcomes? Expressing the client outcome as a nursing intervention Making the outcome measurable and including actions that are observable Including a target time by which the client is expected to achieve the outcome Including a subject, verb, conditions, performance criteria, and target time
Expressing the client outcome as a nursing intervention
A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but his care team wishes to now begin introducing minced and pureed food. How should the nurse best position the client? Fowler's low Fowler's protective supine semi-Fowler's
Fowler's
An older adult woman has been in the hospital for more than 1 week. While assessing her intravenous catheter port, the nurse finds a staph infection, which has developed in the past day or so. This infection is an example of which type of infection? -Healthcare-associated infection -Respiratory infection -Droplet infection - Sexually transmitted infection
Healthcare-associated infection
Which pathologic condition would result in release of antidiuretic hormone (ADH) by the posterior pituitary? Hemorrhage Allergies Obesity Asthma
Hemorrhage ADH is released from the posterior pituitary when stimulated by decreased blood volume and blood pressure (such as with hemorrhage) or increased osmolarity of the blood. Its effect is to retain water to increase circulatory fluid volume and, in turn, increase blood pressure.
A nurse is measuring the apical pulse of a client. Where should she place the diaphragm of her stethoscope in this assessment? Over the space between the fifth and sixth ribs on the left midclavicular line Over the radial artery on the anterior wrist Over the carotid artery in the anterior neck In the center of the upper back
Over the space between the fifth and sixth ribs on the left midclavicular line
What population is at greatest risk for hypertension? Hispanic White Asian Indigenous Australian, Maori and Pacific Islander peoples
Indigenous Australian, Maori and Pacific Islander peoples -more prevalent and more severe in men and women with darker skin coloring, such as the indigenous Australian, Maori, and Pacific Islander peoples.
The nurse is orienting a new unlicensed assistive personnel (UAP) to hospital policies. While a client is participating in physical therapy the UAP decides to make the bed. What are appropriate action(s) by the nurse after entering a hospital room and observing the UAP in the image? Select all that apply. Instruct the UAP to leave the linens on the floor for now and suggest a meeting to discuss the actions being performed Inform the UAP the linens should not be placed on the floor for any reason Communicate the importance of using proper body mechanics to avoid straining the back Assist the UAP to pick up the linens and place them in the linen basket Avoid confronting the UAP until there is a more appropriate time
Inform the UAP the linens should not be placed on the floor for any reason Communicate the importance of using proper body mechanics to avoid straining the back
A new nurse is caring for a client who has a prescription for a stool specimen analysis. As the nurse performs the procedure in the image, the charge nurse walks in to the client's bathroom and observes the new nurse obtaining the specimen. What is next priority action by the charge nurse? -Reprimand the new nurse -Ask the new nurse to leave the client's room immediately -Instruct the new nurse to put more stool in the specimen container to send to the laboratory -Inform the new nurse to wear gloves when obtaining specimens that contains bodily fluids
Inform the new nurse to wear gloves when obtaining specimens that contains bodily fluids Chapter 24: Asepsis and Infection Control - Page 605; 614
The new nurse works at a hospital that uses paper records. The nurse writes a narrative note about administration of a pain medication, pictured above. Based on documentation guidelines, which suggestions would improve the nurse's charting? Select all that apply. Leave no blank space after each entry; draw a line. Identify each entry with AM/PM instead of military time (2400 hour cycle). Sign each entry. Provide qualifiers for pain, such as quality and quantity. Make observations of client behavior, not interpretations. Use different color of ink to highlight medication administration.
Leave no blank space after each entry; draw a line. Sign each entry. Provide qualifiers for pain, such as quality and quantity. Make observations of client behavior, not interpretations.
The Quality and Safety Education for Nurses (QSEN) project has developed quality and safety competency categories. What are the quality and safety competency categories that students are encouraged to develop during prelicensure education? Select all that apply. Nursing process Patient-centered care Therapeutic communication Teamwork and collaboration Evidence-based practice Quality improvement
Patient-centered care Teamwork and collaboration Evidence-based practice Quality improvement
An adolescent with diabetes has a nursing diagnosis of noncompliance related to activities that interfere with the treatment plan as evidenced by elevated blood glucose levels. The outcome for this client is to maintain blood glucose levels between 70 and 110 mg/dL (3.89 and 6.11 mmol/L). The main intervention is to educate the client about the effects of abnormal blood glucose level on the body and ensure that the client has the resources to be compliant. Evaluation reveals that the client's blood glucose level remains elevated and that the outcome has not been met. What is the most appropriate action by the nurse? Modify the plan of care to find alternative ways to meet client needs. Reevaluate the plan of care at a later date. Refer the client to the social worker. Terminate the plan of care because the client will not listen to health care providers.
Modify the plan of care to find alternative ways to meet client needs.
The nurse is caring for a client in protective isolation due to neutropenia as a result of chemotherapy. What priority precaution should the nurse implement in this client? -Ensure client practices proper hygiene to reduce microorganisms on the body -Monitor client for depression and loneliness -Implement periodic infection surveillance reporting -Educate family members on sterile asepsis
Monitor client for depression and loneliness
A female client in a reproductive health clinic tells the nurse practitioner that she douches every day. Should the nurse tell the client to continue this practice? Yes, this helps prevent vaginal odor. Yes, this decreases vaginal secretions. No, douching removes normal bacteria. No, douching may increase secretions.
No, douching removes normal bacteria.
A nurse is using the nursing process to provide care to a client admitted to the facility. During the assessment phase, which activities would the nurse likely perform? Select all that apply. Obtain a baseline oxygen saturation level. Check the results of the client's blood work. Administer prescribed medications. Perform passive range of motion exercises. Obtain a weight
Obtain a baseline oxygen saturation level. Check the results of the client's blood work. Obtain a weight
A nurse is taking care of an older adult client who demonstrates good mobility but is unable to stand for long periods of time secondary to muscle weakness. What action will the nurse use to facilitate the client's self-care and safety? Assist the client in taking a stand-up shower Obtain a shower chair so the client can take a sit-down shower Give the client a bed bath Give the client a towel or bag bath
Obtain a shower chair so the client can take a sit-down shower
A nurse assesses the vital signs of a client who is one day postoperative following a colostomy. The nurse then uses the data to update the client plan of care. What are these actions considered? Initial planning Comprehensive planning Ongoing planning Discharge planning
Ongoing planning
The nurse is completing a sterile dressing change on a confused client. During the procedure, the client reaches down and touches the contents of the open dressing kit. What is the nurse's next action? -Restrain the client's hands -Open a new sterile dressing kit -Continue changing the dressing -Wash the client's hands
Open a new sterile dressing kit
A client has been prescribed graduated compression stockings to wear for the next three weeks. The nurse will implement which interventions? Select all that apply. Measure each leg and take an average to determine size to order. Order at least two pairs of stockings. Plan to put the stockings on the client right before bedtime. Remove the stockings and massage the legs once each day. Launder the stockings at least every three days.
Order at least two pairs of stockings. Launder the stockings at least every three days.
Which group of terms best describes the nursing process? Nursing goals, medical terminology, linear Nurse-centered, single focus, blended skills Patient-centered, systematic, outcome-oriented Family-centered, single point in time, intuitive
Patient-centered, systematic, outcome-oriented
When accessing a client's central line, a drop of the client's blood falls on the nurse's gloved hand. What is the appropriate action by the nurse? - Report the incident to the supervisor immediately - Have the client tested for HIV and hepatitis C - Follow the agency's policy of exposure to communicable infections - Perform hand hygiene after removing the glove
Perform hand hygiene after removing the glove
A client with a stroke has left-sided paralysis. Which action(s) does the nurse take to ensure proper positioning and support for this client? Select all that apply. Place a small pillow under client's waist Straighten the left elbow and support it on a pillow Place the left leg far enough in front of the body to prevent the client rolling onto the back Bend the left knee and support the left leg on a pillow Bend the left arm at a 90-degree angle and place it flat on the bed
Place a small pillow under client's waist Straighten the left elbow and support it on a pillow Place the left leg far enough in front of the body to prevent the client rolling onto the back Bend the left knee and support the left leg on a pillow
The nurse is caring for a client with a latex sensitivity. Which resource would be most appropriate for the nurse to access when developing the client's plan of care? Policy for clients with latex sensitivity The emergency room charge nurse The infectious disease nurse Human resources department
Policy for clients with latex sensitivity
Which function of the skeletal system is essential to proper function of all other cells and tissues? Supporting soft tissues of the body Protecting delicate body structures Providing storage area for fats Producing blood cells
Producing blood cells
A student has been assigned to provide morning care to a client. The plan of care includes information that the client requires partial care. What will the student do? Provide total physical hygiene, including perineal care. Provide total physical hygiene, excluding hair care. Provide supplies and orient the client to the bathroom. Provide supplies and assist with hard-to-reach areas.
Provide supplies and assist with hard-to-reach areas.
Upon review of the client's orders, the nurse notes that the client was recently started on an anticoagulant agent. What is an appropriate consideration when assisting the client with morning hygiene? Provide the client with an electric shaver. Provide the client with a firm-bristled toothbrush. Do not allow the client to shower. Avoid massaging the client's back with lotion.
Provide the client with an electric shaver.
The nurse is planning the care of a client who is receiving treatment for acute renal failure and who has begun dialysis 3 times weekly. The nurse has identified the following outcome: "Client will demonstrate the appropriate care of an arteriovenous fistula." This outcome is classified as which? Psychomotor Affective Cognitive Holistic
Psychomotor
The nurse is caring for a client who has been newly diagnosed with diabetes. One of the outcomes the nurse read on the client's plan of care this morning was: "Client will demonstrate correct technique for self-injecting insulin." The client required insulin prior to lunch and successfully drew up and administered the insulin while the nurse observed. How should the nurse follow up this observation? Record an evaluative statement in the client's plan of care. Remove the outcome from the client's care plan. Ask the nurse who wrote the plan of care to document this development. Reassess the client's psychomotor skills at dinner time.
Record an evaluative statement in the client's plan of care.
A nurse has an order to take the core temperature of a client. At which site would a core body temperature be measured? Rectal Oral Skin surface Axillary
Rectal
The nurse charted the administration of preparation for a colonoscopy in the AM in the progress notes of the client's paper chart, pictured above. Which correct documentation guidelines did the nurse follow? Select all that apply. Sign every entry Document in chronological order Identify the day and time for each entry Leave blanks in the charting Acknowledge the client's response to the medication
Sign every entry Document in chronological order Identify the day and time for each entry Acknowledge the client's response to the medication
A nurse caring for a client who has gas gangrene knows that this infection originated in which of the following reservoirs? -Other people -Food -Soil -Animals
Soil soil can act as a reservoir; the organisms that cause gas gangrene and tetanus are examples of pathogens whose reservoir is soil
The nurse begins a task and then realizes that personal protective equipment (PPE) is needed. What is the correct action by the nurse? -Stop and obtain appropriate PPE. -Complete the task, then obtain PPE. -Ask a colleague to perform the task. -Leave PPE in the room.
Stop and obtain appropriate PPE.
A nurse is inserting a client's urinary catheter and notices a hole in one of the sterile gloves and that his hands are soiled. What would be the most appropriate action to take in order to maintain a sterile field? - Finish the procedure and perform handwashing immediately afterward. - Finish the procedure, remove damaged glove, and open new sterile gloves. -Stop the procedure, remove damaged glove, and open new sterile gloves. -Stop the procedure, remove damaged glove, perform handwashing, and open new sterile gloves.
Stop the procedure, remove damaged glove, perform handwashing, and open new sterile gloves.
Which is an example of a long-term goal for a client with asthma? The client will return home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack. By day 3 of hospitalization, the client will verbalize knowledge of factors that exacerbate the symptoms of asthma. Within 1 hour after a nebulizer treatment, adventitious breath sounds and cough will decrease. Within 72 hours after admission, the client's respiratory rate will return to normal and retractions disappear.
The client will return home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack.
The home health nurse is providing care to a number of clients. Which client assessed by the nurse will require hospitalization related to complications associated with the feet? The client with peripheral vascular disease The client who has osteoporosis The client who has asthma The client experiencing diabetes insipidus
The client with peripheral vascular disease
The nurse who performs the admission nursing history and physical assessment makes the initial plan. select all that apply. The nurse who performs the admission nursing history and physical assessment makes the initial plan. After the initial plan is developed, the nurse prioritizes nursing diagnoses. The nurse identifies client goals and the related nursing care in the initial plan. The nurse uses tailored plans as opposed to standardized care plans as a basis for the initial plan. The nurse collects new data and analyzes them to make the plan more specific and effective. The nurse making the initial plan focuses on using education and counseling skills to help the client carry out necessary self-care behaviors at home.
The nurse who performs the admission nursing history and physical assessment makes the initial plan. After the initial plan is developed, the nurse prioritizes nursing diagnoses. The nurse identifies client goals and the related nursing care in the initial plan.
What is the primary purpose of the outcome identification and planning step of the nursing process? To collect and analyze data to establish a database To interpret and analyze data so as to identify health problems To write appropriate client-centered nursing diagnoses To design a plan of care for and with the client
To design a plan of care for and with the client
The nurse provides care for a female client having difficulty urinating after a vaginal hysterectomy. Which strategy(ies) does the nurse use to assist the client with urinary elimination? Select all that apply. Turn on the water in the bathroom Pour warm water over the perineum Place client in sitting position Provide a sitz bath Encourage client to drink large quantities of water
Turn on the water in the bathroom Pour warm water over the perineum Place client in sitting position Provide a sitz bath
An older adult resident of a long-term care facility has recurring problems with dry skin. Which strategy should the nursing staff utilize in order to help meet the resident's hygiene needs while preventing skin dryness? Use a nonsoap cleaning agent. Use organic soap and shampoo. Bathe the client more often, but without using soap or shampoo. Provide the client with bed baths rather than tub baths.
Use a nonsoap cleaning agent
A nurse is providing foot care to an elderly client who has diabetes and decreased mobility. What technique would the nurse employ when providing foot care? Use an antifungal powder on the client's feet if necessary. Carefully remove any corns or calluses that are present. Soak the client's feet for 15 to 20 minutes in hot water prior to cleansing. Avoid using soaps or commercial cleansers whenever possible.
Use an antifungal powder on the client's feet if necessary.
A client who is an avid runner has been monitoring her pulse at home. Recently, her pulse has been below the normal range of 60 to 100 bpm for adults. Today her pulse is 58 bpm. The client asks the nurse at her annual screening if she should be concerned. What is the most appropriate response by the nurse? -Physical exercise usually increases the pulse rate; therefore, we will admit you into the hospital for further testing. -Well-conditioned athletes can run lower pulse rates because of -the greater efficiency and strength of the heart muscle from regular cardiovascular exercise. -Why are you concerned? You seem healthy. -You should stop running until your pulse rate is within the normal range again.
Well-conditioned athletes can run lower pulse rates because of the greater efficiency and strength of the heart muscle from regular cardiovascular exercise. Physical exercise can cause an increase in pulse rate but well-conditioned athletes can have lower pulse rates because of the greater efficiency and strength of the heart muscle from regular cardiovascular exercise.
A nurse is helping an older woman undress and notices the woman's knee-high hose have left deep indentations. The woman has diabetes. Does this pose a risk to the client? No, the indentations will go away. No, knee-high hose are more comfortable. Yes, these are a safety hazard and should not be worn. Yes, these can obstruct lower extremity circulation.
Yes, these can obstruct lower extremity circulation
Why is it important for the nurse to teach and role model proper body mechanics? to ensure knowledgeable client care to promote health and prevent illness to prevent unnecessary insurance claims to demonstrate knowledge and skills
to promote health and prevent illness
A woman tests positive for the human immunodeficiency virus antibody but has no symptoms. She is considered a carrier. What component of the infection cycle does the woman illustrate? -a reservoir -an infectious agent -a portal of exit -a portal of entry
a reservoir
A man on an airplane is sitting by a woman who is coughing and sneezing. If she has an infection, what is the most likely means of transmission from the woman to the man? direct contact indirect contact vectors airborne route
airborne route organism may be transmitted from its reservoir by various means or routes. Microorganisms can be spread through the airborne route when an infected host coughs, sneezes, or talks (direct contact) or when the organism becomes attached to dust particles (indirect contact).
An obstetrics nurse is preparing to help a client up from her bed and to the bathroom 3 hours after the woman gave birth. Which action should the nurse perform first? explain to the client how the nurse will assist her position a walker in front of the client to provide stability enlist the assistance of another nurse or the physiotherapist have the client stand for 30 seconds prior to walking
explain to the client how the nurse will assist her
The following are prescriptions on a client's chart. Which prescriptions would the nurse question because they are written incorrectly? Select all that apply. 1000 mL NS IV q8h lytes in AM heparin 5000U subcutaneously every day metoprolol 25 mg po daily, hold if BP <100 mm Hg CXR tonight vancomycin 750 mg IV qod
heparin 5000U subcutaneously every day metoprolol 25 mg po daily, hold if BP <100 mm Hg vancomycin 750 mg IV qod
When the nurse is administering furosemide 20 mg to a client in congestive heart failure, what phase of the nursing process does this represent? assessment planning implementation evaluation
implementation
While performing a physical examination on a client, the nurse observes that the client has scoliosis based on: lateral deviation of the thoracic spine. concave curvature of the cervical spine. convex curvature of the thoracic spine. concave curvature of the lumbar spine.
lateral deviation of the thoracic spine.
Which client would be at greatest risk for injury to the skin and mucous membranes? infant 10 days old with no health problems adolescent 17 years of age with asthma man 44 years of age with hemorrhoids man 77 years of age with diabetes
man 77 years of age with diabetes
The nurse managers of a home health care office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which documentation format is most likely to promote this goal? narrative notes SOAP notes FOCUS charting charting by exception
narrative notes
While receiving a report, the nurse learns that a client has paraplegia. The nurse will plan care for this client based upon the understanding that the client has: paralysis of the legs. weakness affecting one-half of the body. paralysis affecting one-half of the body. paralysis of the legs and arms.
paralysis of the legs.
The nurse assists the client to the bathroom sink to perform morning care. The nurse observes the client wash his face, arms, abdomen, and legs. The nurse washes the client's back and rectal area and applies soap to the back. The client brushes his teeth and ambulates to a chair in his room with assistance. How will the nurse describe the morning care on the client's chart? partial care as-needed care self-care complete care
partial care
Which method of documentation is organized around client diagnoses rather than around client information? problem-oriented medical record (POMR) source-oriented record PIE charting system FOCUS charting
problem-oriented medical record (POMR)
A benefit of using computerized plans of nursing care is: reduction in the time spent on care planning. increased autonomy related to the nursing care planning process. enhanced individualization of a care plan. increased nursing expertise in care planning.
reduction in the time spent on care planning.
What organ is the primary site of heat loss in the body? skin lungs heart kidneys
skin skin is the primary site of heat loss in the body
In what type of documentation does a nurse record narrative notes in a nursing section? problem-oriented medical record source-oriented record PIE charting system FOCUS charting
source-oriented record
A nurse is assessing a client who has a fever, has an infection of a flank incision, and is in severe pain. What type of pulse rate would the client most likely exhibit? bradycardia tachycardia dysrhythmia bigeminal
tachycardia The pulse rate increases (tachycardia) and decreases in response to a variety of physiologic mechanisms. Tachycardia is a response to an elevated body temperature and pain.
A nurse is providing care for a client who has been newly admitted to the long-term care facility. What is the primary criterion for the nurse's decision whether to use a mechanized assistive device for transferring the client? the client's ability to assist the client's body weight the client's cognitive status the client's age
the client's ability to assist
Before a long-term care resident goes to sleep at night, the client's dentures are placed in a denture cup with clean water. What rationale supports placing dentures in water? none; they should be placed in saline to increase comfort when replaced in the mouth to prevent drying and warping of plastic to ensure the dentures are not thrown away
to prevent drying and warping of plastic client removes dentures while sleeping, they should be stored in water in a disposable denture cup to prevent drying and warping of plastic materials. If the dentures warp, then the client will experience discomfort in eating.
Which nursing action demonstrates safe injection practice? -recap needles if necessary -use sterile single-use disposable syringes for each injection -clean injection equipment when dust becomes visible -use multiple-dose vials when administering medication to multiple clients
use multiple-dose vials when administering medication to multiple clients
A nurse is educating a rural community group on how to avoid contracting West Nile virus by using approved insect repellant and wearing proper coverings when outdoors. By what means is the pathogen involved in West Nile virus transmitted? -direct contact -indirect contact -airborne route -vectors
vectors
The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which drawback? vulnerability to legal liability since nurse's safe, routine care is not recorded increased workload for nurses in order to complete necessary documentation failure to identify and record client problems and associated interventions significant differences in the charting between nurses due to lack of standardization
vulnerability to legal liability since nurse's safe, routine care is not recorded
A student has reviewed a client's chart before beginning assigned care. Which action violates client confidentiality? writing the client's name on the student care plan providing the instructor with plans for care discussing the medications with a unit nurse providing information to the physician about laboratory data
writing the client's name on the student care plan
