Final study questions nur 101
"Would you like to talk about what's bothering you?"
A client exhibits signs of increased anxiety. Which response by the nurse is most likely to reduce the client's anxiety?
Interview the client further to gather more details.
A client expresses a desire to discuss spiritual and religious beliefs with someone. What is the best nursing intervention at this point?
Approach the client and ask if there are questions about the condition.
A client has been diagnosed with colon cancer with metastasis to the lymph nodes. When the nurse enters the room, the client says life is "not worth living." What is the nurse's best therapeutic response?
240
A client is to take 8 ounces of magnesium sulfate solution. The calibrations on the measuring device are in milliliters. How many milliliters should the nurse give?
Maintain eye contact while talking
A client of Anglo-Saxon descent (e.g., Anglo-American or English Canadian) reports to the primary healthcare facility with symptoms of fever, cough, and running nose. While interviewing the client, which points should the nurse keep in mind?
The nurse should listen attentively and provide realistic verbal reassurance
A client scheduled for a total laryngectomy and radical neck dissection begins talking rapidly, commenting, "I'm really nervous and scared about the operation." What is the most therapeutic action by the nurse?
interpersonal skills
A client scheduled to have a surgery for a hernia the next day is anxious about the procedure. The nurse assures the client that surgery for hernias is very common and that the prognosis is very good. What skill is the nurse demonstrating?
Inform the nurse director reading the chart is a violation of the client's right to privacy and ask the nurse director to return the chart.
A client who tested positive for human immunodeficiency virus (HIV) and has pancreatitis is admitted to the medical unit. The nurse director from another unit comes into the medical unit nurses' station and begins reading the client's chart. The staff nurse questions the director about reading the client's chart. The director states that the client is a neighbor's son. What action should the nurse take?
"I would like to sit with you and talk about your child."
A client whose child has died is withdrawn, has flat affect, makes minimal eye contact, and states, "I can't live without my child." What is the most appropriate response by the nurse?
Document the client's choice and re-assess pain in 1 hour.
A client with cancer-related pain has been prescribed a narcotic analgesic to be given around the clock. The client is competent and has been actively involved in decisions regarding care. What should the nurse do if the client refuses the next dose of analgesia?
"What ways have you used to help reduce stress and cope with significant events in your life?"
A client with two young children is diagnosed with breast cancer. The client says, "This is the worst time in my life. How can I adjust to all of this without losing it?" What is the nurse's best reponse?
moxifloxacin 400 mg daily
A client's diagnosis of pneumonia requires treatment with antibiotics. The corresponding order in the client's chart should be written as
"Your behavior in this situation is considered verbal abuse."
A community nurse arrives at the home of a client. The client is in soiled clothes due to the inability to make it to the bathroom in time. The nurse overhears the unregulated care provider (UCP) scolding the client for the soiled clothes. What is the most appropriate response by the nurse to the UCP?
Receive the prescription over the phone and repeat it back to the HCP to verify accuracy.
A healthcare provider (HCP) calls the hospital unit and requests to leave a new prescription for a client over the phone as the HCP does not have access to the electronic health record (EHR) at present. What action would the nurse take?
inform the nursing supervisor
A nurse finds that a colleague is intoxicated while on duty. What appropriate action would the nurse take?
what the nurse saw and did
A nurse has made a medication error. Which information is appropriate to include in the incident report?
Address the nurse's omissions as negligent behavior.
A nurse is caring for a client with a fresh postoperative wound following a femoral-popliteal revascularization procedure. The nurse fails to routinely assess the pedal pulses on the affected leg, and missed the warning sign that the blood vessel was becoming occluded. The nurse manager is made aware of the complication and the nurse's failure to assess the client properly. What action should be taken by the nurse manager?
Explain the use of an advance directive to express the client's wishes.
A nurse is caring for a client with advanced cancer. Based on the accompanying nursing progress notes, what should be the nurse's next intervention?
Incident report.
A nurse is documenting a variance that has occurred during the shift, and this report will be used for quality improvement to identify high-risk patterns and potentially initiate in-service programs. This is an example of which type of report?
"It sounds like that offers you a sense of security."
A nurse is giving a bed bath to a terminally ill client. The client tells the nurse that the client has great respect and faith in a particular spiritual leader. Which is the best response by the nurse?
People of Asian descent prefer some distance between themselves and others.
A nursing instructor has assigned a student to care for a client of Asian descent. The instructor reminds the student that personal space considerations vary among cultures. What personal space preferences are important for the student to consider when caring for this client?
primary prevention
An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of health promotion?
Ensure case management is actively involved in the client's care to facilitate care coordination
An older adult who lives alone is admitted to the hospital for debility and weakness. What is the most important intervention to ensuring cost-effective care is provided for this client?
Include the time and date of the incident.
During rounds, a nurse finds that a client with hemiplegia has fallen from the bed because the nursing assistant failed to raise the side rails after giving a back massage. The nurse assists the client to the bed and assesses for injury. As per agency policies, the nurse fills out an incident report. Which activity should the nurse perform after finishing the incident report?
to protect the safety of the public
Professional regulations and laws that govern nursing practice are in place for which reason?
"It sounds like you are overwhelmed. How can we better support you through this process?"
The home health nurse attends to a terminally ill client whose older adult spouse is the primary caregiver. The spouse states, "I am so ashamed to admit that sometimes I wish it would all just end. I am so tired." How should the nurse respond?
Plan and implement care in a way that is sensitive to the needs of the client.
The nurse cares for a client of a different cultural background. What is the best way for the nurse to provide culturally competent care to the client?
Within 30 minutes the client says that the pain is reduced.
The nurse gives a client an oral narcotic analgesic medication to treat postoperative pain. Which follow-up assessment most clearly indicates that the treatment was effective?
"Enduring pain is a part of God's will."
The nurse is assessing the pain level in a client who typically gives a stoic response to describing the pain. Which comment from this client is expected?
ending each entry with a signature and title
The nurse is documenting client information in the client's medical record. Which action by the nurse is appropriate when documenting information in a client's medical record?
Assessment
The nurse uses which part of the SBAR acronym when stating, "I think the client is dry."
Console the roommate as grieving begins.
The roommate of a recently deceased client is observed sitting in the client lounge crying. What should the nurse do to support this person?
"Let's discuss how we can meet our clients' needs."
The unlicensed assistive personnel tells the nurse that it is unreasonable to expect a response to all call lights within 10 minutes. Which statement by the nurse best illustrates appropriate assertive behavior by a supervisor?
"You are not authorized to view all of the details on the client."
The unlicensed nursing assistant is viewing the electronic medical record of an assigned client. When the assistant tries to access notes made by the social worker, an error message appears on the screen that reads, "You are not authorized to view this information." The assistant questions the nurse about this message. What response would the nurse make?
limiting abbreviations to those approved for use by the institution
When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes
An emergency department nurse reports suspected child abuse.
Which situation demonstrates correct principles of confidentiality?
