FINAL (PrepU assignment review)
A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response?
"It allows for removal of blood and drainage from the surgical wound."
A nurse is assessing the blood pressure of a client who has come to the health care facility for the first time. What is the best site for obtaining the client's blood pressure reading?
Arm
A client who was injured when he stepped on a rusted nail visits the health care facility. How should the nurse describe this wound?
Puncture
The acronym health care workers use to remember the safety procedures in the event of fire is:
RACE (rescue; alarm; confine; evacuate).
A nurse needs to measure the pulse of a client admitted to the health care facility. Which site would the nurse most likely use?
Radial
A nurse has an order to take the core temperature of a client. At which of the following sites would a core body temperature be measured?
Rectal
The nurse preparing to perform an abdominal assessment on a client places the client in which of the following positions?
Supine
While caring for an older adult male, the nurse observes that his skin is dry and wrinkled, his hair is gray, and he needs glasses to read. Based on these observations, what would the nurse conclude?
These are normal physiologic changes of aging.
A nurse takes a client's vital signs. Which of the following is considered a vital sign?
blood pressure
When the home care nurse visits a female client age 78 years who is recently widowed, the nurse finds that the home is cluttered with trash. The client appears sad and disheveled. The nurse should assess the client for symptoms of:
depression.
Which type of wound drainage should alert the nurse to the possibility of infection?
foul-smelling drainage that is grayish in color
A home care nurse makes the following assessments of a wound: increased drainage and pain, increased body temperature, red and swollen wound, and purulent wound drainage. What wound complication do these assessments indicate?
infection
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?
"Monitoring your BP at home will assist in controlling your BP, thereby decreasing your risk for heart attack and stroke."
A nurse is educating the family caregiver of an older adult client about measures to promote client safety in the home. What would be most appropriate to include?
"Clear the clutter from the stairways and walkways."
A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during dressing changes. Which response by the nurse is appropriate?
"I respect your wish not to look at it right now."
An adolescent comes to a community health clinic reporting vaginal itching and discharge. She believes it is from having sex with her boyfriend. Which response should the nurse use during the health history to elicit information?
"Tell me about the sexual activity with your boyfriend."
A nurse is conducting a health history for a client with a skin problem. What question or statement would be most useful in eliciting information about personal hygiene?
"Tell me about what you do to take care of your skin."
A nurse is caring for a client with a diagnosis of metastatic lung cancer. The nurse finds the client sitting in a chair while staring out the window. The nurse conveys caring by saying:
"Tell me what is on your mind."
A nurse is caring for a client with long hair. The client asks if something could be done about her hair to be more comfortable. How would the nurse respond?
"Yes, I can braid it for you if you want me to."
A nurse is completing a health history with a client being admitted for a mastectomy. During the interview, the client states, "I don't know what to do. I am not sure if I really need this surgery." Which response by the nurse demonstrates active listening?
"You seem unsure. Tell me your concerns about your surgery."
A female client asks the nurse why she urinates more frequently as she is getting older. Which of the following is the nurse's best response?
"Your bladder capacity decreases with age."
After taking vital signs, the nurse writes down findings as T = 98.6 (37), P = 66, R = 18, BP = 124/82. Which number represents the systolic blood pressure?
124
A nurse is caring for clients on a medical surgical unit. Based on known risk factors, the nurse understands which client has the highest risk for developing a pressure ulcer?
65-year-old incontinent client with a hip fracture on bed rest
What is an example of nonverbal communication?
A client's face is contorted with pain.
The nurse should explain to the client's family member that a comfort-measures-only order is being implemented to obtain which expected outcome?
A comfortable, dignified death for the client
A teenager states, "Old people are different. They don't need the same things that young people do." What is this statement an example of?
Ageism
A nurse making a home visit for a client living in a high-crime area observes that the apartment building does not have outside lighting. The nurse understands this is an important assessment for which reason?
Assessment includes risk factors in the home including individual risk and unsafe environment
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 of the following actions will she perform?
Create a calming environment with little stimuli.
A nurse is preparing to assess a client with abdominal pain. What should the nurse do when preparing the client for assessment?
Explain the assessment procedure to the client.
During a nurse's visit to the client's home, the client states, "I have pain in my right knee." The nurse assesses the client's right knee. What kind of assessment is this?
Focused assessment
What intervention should be included on a plan of care to prevent pressure ulcer development in health care settings?
Implement a turning schedule every 2 hours.
What assessment technique would the nurse use to assess a client's chest for color, shape, or contour?
Inspection
Upon assessment of an older adult, the nurse notes the client's skin to have a yellow color. The nurse recognizes and documents this skin color as which of the following?
Jaundice
A nursing student is preparing to perform a head-to-toe assessment of a hospital patient. How can the nurse best protect the patient's comfort level during the assessment?
Keep unexamined body parts covered until they need to be examined.
A dying client and family have requested that no attempts be made to resuscitate the client in the event of death. A doctor has written a DNR order. What is the nurse's responsibility if the client dies?
Make no attempt to resuscitate the client.
The dressing change on a deep upper-arm wound is painful for the client. When preparing a care plan for the client, the nurse will incorporate which nursing measure?
Plan to administer a prescribed analgesic 30 to 45 minutes prior to the dressing change.
An emergency room nurse is assessing a toddler with multiple bruises and burns. The nurse suspects the toddler has been abused. What is legally required of the nurse?
Report suspicions about the abuse to proper authorities.
After a client falls out of bed, the nurse completes which of the following?
Safety event report (incident report)
What organ is the primary site of heat loss in the body?
Skin
While conducting a health assessment with an older adult, the nurse notices it takes the person longer to answer questions than is usual with younger clients. What should the nurse do?
Slow the pace and allow extra time for answers.
The nurse is assessing an adult who has a pulse rate of 180 beats/min. Which condition would the nurse document?
Tachycardia
Which situation would lead the client's family to suspect onset of dementia?
The client has increasingly experienced disorientation to familiar surroundings.
Why is communication important to the "assessment" step of the nursing process?
The major focus of assessing is to gather information.
Mr. Cooney, age 85, is in advanced stages of pneumonia with a no-code order in his chart. Which nursing care action will help establish a trusting nurse-client relationship?
The nurse discusses the client's fears and doubts openly and serves as a nonjudgmental listener.
A team of inner city school nurses attends a community conference on child safety during the summer months. What would be the priority health outcome that these nurses would expect to achieve in summer school?
The students will demonstrate proper use of safety equipment while playing sports.
Which factor is most important in the development of rapport between nurse and client?
Trust
A client that is an avid runner has been monitoring her pulse at home. Recently, her pulse has been below the normal range of 60-100 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?
Well-conditioned athletes can run lower pulse rates because of the greater efficiency and strength of the heart muscle from regular cardiovascular exercise.
A nurse working in long-term care is assessing residents at risk for the development of a pressure ulcer. Which one would be most at risk?
a client 86 years of age who is bedfast
The nurse is planning an educational event for a group of senior citizens on the topic of the normal signs of aging. What would the nurse include in the education plan?
a decrease in muscle mass
What is the most accurate definition of a wound?
a disruption in normal skin and tissue integrity
A terminally ill client states, "I am ready to die." What stage of grief does the nurse suspect?
acceptance
A nurse is conducting a prenatal class for expectant parents. What is one topic that should be addressed to promote safety in the developing fetus?
alcohol consumption and smoking
A nurse is performing a home assessment for a 90-year-old widower who lives in a third story apartment. As the nurse considers his home environment, the nurse knows that the greatest risk of injury-related death or disability for the client comes from:
falls
The nursing instructor is observing a nursing student who is about to administer a medication. Which nursing student behavior concerning client identification does the nursing instructor validate as appropriate?
identifies client's full name and date of birth
When examining a client upon admission to the hospital, it is important to:
provide privacy and confidentiality.
A nurse is taking care of an older adult woman who demonstrates good mobility but is unable to stand for long periods of time secondary to muscle weakness. Which method for bathing would be most appropriate for this client?
sit-down shower with shower chair
A middle-age, overweight adult client has had hypertension for 15 years. The pathologic event the client is most at risk for is:
stroke.
A nursing student assesses a blood pressure on an adult and finds it to be 140/86. What term is used for the top number (140)?
systolic pressure
A nurse is providing perineal care to a female client. In which direction would the nurse move the washcloth?
trom the pubic area toward the anal area
A nurse uses observation to examine a client's skin. The nurse would document cyanosis for the client:
whose skin is a dusky, bluish color.