Fun 3
What is the correct name of the documentation that identifies a legal proxy for making healthcare decisions in case the client is unable to make those decisions? A) Living will B) Do-Not-Resuscitate order C) Durable power of attorney D) Client choice record
C
A client who has sustained a neck injury is unresponsive and pulseless. What should the ER nurse do to open the client's airway? A. Insert oropharyngeal airway B. Tilt the head and lift the chin C. Place in the recovery position D. Stabilize the skull and push up the jaw
D
While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following is the appropriate intervention? A. Have a client hold his breath briefly B. Discontinue the fluid installation. C. Remind the client that cramping is common at this time. D. Lower the enema fluid container.
D
he nurse instructs a client to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of the pursed-lip breathing is to promote which outcome? A. Promote oxygen intake B. Strengthen the diaphragm C. Strengthen the intercostal muscles D. Promote carbon dioxide elimination
D
Which of the following items uses an acceptable abbreviation, dose designation, or symbol in a medical record (select all that apply)? A. Regular insulin 5 u SQ B. MSO4 2g IV q 2 hours prn pain C. Cholecalciferol 1000 IU daily D. Client c/o right-sided hip pain E. Neurology check QID
D, E
A nurse is caring for a client who is on a mechanical ventilator and who receives nutrition through a feeding tube. Which position is likely to reduce the risk of this client developing aspiration pneumonia? a. supine with the head of the bed elevated 30 to 45 degrees b. right side-lying c. supine with the head of the bed elevated 15 degrees d. Sim's position
A
A nurse is caring for a client who uses oxygen and who smokes. The client says, "I know I shouldn't smoke, but I can't seem to quit." Which response from the nurse is most appropriate? A. You are putting yourself in danger when you smoke around oxygen; Let's talk about some options to help you quit B. I know it is difficult to quit smoking, but if you continue to smoke, we will have to discontinue using the oxygen C. You are negating the effect of the oxygen when you smoke, so we will discontinue the order until you are ready to quit D. You should be able to smoke 1 to 2 cigarettes a day and be safe, even if you use oxygen.
A
A nurse is documenting information about a client's bladder irrigation. Which information is most important to include in the documentation of the procedure? a. Date and time of catheter insertion b. Character and frequency of the client's stool c. Vital signs every 8 hours d. Assessment of the client's pain every day
A
A nurse is providing discharge teaching to a patient with a new colostomy. The client asks if it is all right to get the colostomy bag wet. Which of the following is the most appropriate response? a. "Yes, you can get it wet, but you may want to empty it before swimming or bathing." b. "Yes, you can get it wet if you use a specially-designed waterproof bag." c. "No, you cannot get it wet, and you should apply a plastic wrap or plastic bag before swimming or bathing." d. "No, you cannot get it wet, and you should remove the bag before swimming or bathing."
A
A patient has not had a bowel movement for 4 days. Now she has nausea and severe cramping throughout her abdomen. On the basis of these findings, what do you suspect is wrong with the patient? A. An intestinal obstruction B. Irritation of the intestinal mucosa C. Gastroenteritis D. A fecal impaction
A
Which of the following is an expected outcome for a client who is recovering from an abdominal perineal resection with a colostomy? The client will: A. Resume walking on the hospital floor soon after surgery B. Eliminate fiber from diet C. Permanently limit physical activity to light exercise D. Anticipate urinary self-catherization
A
A home health nurse is helping a client who uses oxygen at home. Which of the following instructions should be included as part of teaching for this client, to keep him safe around oxygen? (select all that apply.) A. tell the client to avoid using oxygen around electrical equipment B. Avoid taking the oxygen tank outside the home C. Only use the oxygen amount that has been ordered by the health care provider D. Only smoke when oxygen has been moved at least 5 feet from the smoker E. Store the oxygen tank upright in an approved container
A, C, E
A nurse is caring for a patient with hemorrhoids. Which of the following does the nurse expect the health care provider to recommend for management of this condition? (Select all that apply) a. topical analgesic ointment b. astringent pads c. low-fiber diet d. fluid restriction e. iron supplementation
A, B
A nurse is assessing a client with arterial blood gas values pH 7.49, PaO2 90 mm Hg and a PaCO2 of 31 mm Hg. What clinical manifestations may be associated with the client's arterial blood gas results? (Select all that apply.) A) Dizziness B) Tingling in hands C) Tetany D) Bradycardia E) Increased bicarbonate level
A, B, C
A nurse is documenting care in the medical record of a client following a cardioversion. The nurse should include which of the following information in the documentation? A. The clients ECG rhythm following the procedure B. The energy settings used for the procedure C. The restocking of defibrillator supplies following the procedure D The recharging of the defibrillator following the procedure E. The condition of the client's skin under the electrodes following the procedure
A, B, E
Which of the following interventions does a nurse anticipate when planning care for a client who has a small bowel obstruction who has a nasogastric tube in place? (Select all that apply) A. provide oral hygiene every 2 hours B. monitor the placement of the nasogastric tube every 24 hours C. document nasogastric drainage along with other client output D. assess bowel sounds E. irrigate the nasogastric tube every shift
A, C, D
Which of the following interventions should the nurse anticipate when planning care for a client who has a small bowel obstruction who has a nasogastric tube in place? (Select all that apply). A) Provide oral hygiene every two hours B) Monitor placement of the nasogastric tube every 24 hours C) Document nasogastric drainage along with other patient output D) Assess bowel sounds E) Irrigate the nasogastric tube ever shift
A, C, D
The nurse is supervising a beginning nursing student and allowing the student to complete documentation of care under direct supervision. Which of the following actions are not appropriate and would require intervention? (Select all that apply.) A. Documents a medication given by another nursing student. B. Includes the date and time of entry into the medical record. C. Enters assessment data into the electronic medical record using the computer mounted on the wall in the patient's room. D. Leaves a slip of paper with her user name and password in the patient's room. E. Starts to enter "Docusate sodium 100 mg ordered at 08:00 held. Patient declined dose stating, 'I had several loose stools yesterday, and I'm afraid if I take this dose the problem will get worse,'" as a narrative comment.
A, D
The nurse is developing a plan for a patient who was diagnosed with narcolepsy. Which interventions should the nurse include on the plan? (Select all that apply) A. Take brief, 20 minute naps no more than twice a day. B. Drink a glass of wine with dinner C. Eat the large meal at lunch rather than dinner. D. Establish a regular exercise program E. Teach the patient about the side effects of modafinil (Provigil)
A, D, E
A nurse is caring for a client who has been diagnosed with irritable bowel syndrome. Which of the following findings does the nurse anticipate on assessment of this client? (Select all that apply) A. constipation B. bright red blood per rectum C. melena D. steatorrhea E. feelings of incomplete evacuation
A, E
Which instruction do you include when educating a person with chronic constipation? (Select all that apply.) A. increase fiber and fluids in the diet B. Use a low-volume enema daily C. Avoid gluten in the diet D. Take laxatives twice a day E. Exercise for 30 minutes every day F. Schedule time to use the toilet at the same time everyday G. Take probiotics 5 times a week
A, E, F
A nurse is assessing a child who complains of a nonproductive cough for two days. The child is active and alert, with pink skin and a good capillary refill. During the initial assessment, the nurse notes the child has an oxygen saturation of 88% by continuous pulse oximetry. Which is the most appropriate initial action? a. provide 2L supplemental oxygen by nasal cannula b. verify the position of the pulse oximetry probe c. draw arterial blood gases d. auscultate the lungs
B
A nurse is assisting a client with anxiety disorder in a meditation exercise. This is an example of which of the following types of communication? A. Interpersonal B. Transpersonal C. Intrapersonal D. Nonverbal
B
A nurse is providing education about dietary recommendations for a client with irritable bowel syndrome. Which of the following menu choices reflects client understanding? A. bananas, cabbage, and milk B. fish, pita bread, and beef broth C. pork chops, honey, and tea D. beans
B
A nurse is transcribing several new prescriptions into client's electronic medical records. Which of the following documentation has the nurse entered correctly? a. Losartan 50.0 mg PO QD b. Paroxetine 20 mg PO daily c. Desmopressin .15 mL intranasally QD d. Prednisolone solution 5 mg PO OD
B
A nurse realizes he made an error when documenting an item found on a client assessment. What is the appropriate way to correct the record? a. use white out to delete the error and then complete with correct data b. draw a line through the error and then initial and date it c. add a late entry to the record d. erase the error to make space for the correct entry
B
The nurse is preparing to assess the respirations of several newborns in the nursery. The nurse performs the procedure and determines that the respiratory rate is normal if which findings is noted? A. A respiratory rate of 30 breaths per minute in a crying newborn B. A respiratory rate of 46 breaths per minute in an awake newborn C. A respiratory rate of 60 breaths per minute in a sleeping newborn D. A respiratory rate of 76 breaths per minute in a newly delivered newborn
B
A nurse is preparing discharge teaching for a client with COPD who has a new prescription for home oxygen by nasal cannula. Which of the following statements indicate that the client needs further teaching (select all that apply)? A. "I should not sit by burning candles when using oxygen" B. "I should increase the flow of oxygen if I feel short of breath" C. "I should use a nylon blanket on my bed" D. "I should only use a water-based lubricant if my nose becomes dry" E. "I should not use nail polish remover when using oxygen"
B, C
The nurse uses silence as a therapeutic communication technique. What is the purpose of the nurse's silence? (Select all that apply) A. Prevent the nurse from saying the wrong thing B. Prompt the patient to talk when he or she is ready C. Allow the patient time to think and gain insight D. Allow time for the patient to drift off to sleep E. Determine if the patient would prefer to talk with another staff member
B, C
Which of the following cause Clostridium difficile infection? (Select all that apply) A. Chronic laxative use B. Contact with C. difficile bacteria C. Overuse of antibiotics D. Frequent episodes of diarrhea caused by food intolerance E. Inflammation of the bowel
B, C
A client is critically ill and admitted to a step-down unit. Which of the following nursing interventions promote normal rest and patterns of sleep? (select all that apply.) A. increase continuous infusion of IV sedation during evening and nighttime hours B. open curtains in the morning C. turn off equipment alarms in the room at night D. Dim the light at night E. Keep the client busy with scheduled tests and therapeutic activities during the daytime
B, D, E
A client who is receiving supplemental oxygen by nasal cannula at 5 L/min complains of discomfort and dryness of his nose. Which of the following interventions may resolve the client's complaint? A. A face mask should be used in place of the nasal cannula B. The client should sit upright in a chair C. The oxygen should be humidified D. The client should use several extra pillows in bed
C
A nurse is caring for a client with COPD who has a prescription for a precise oxygen concentration. Which of the following is the best oxygen delivery system for this client? A. Face mask B. Nasal cannula C. NG tube D. Venturi mask
D
A nurse is caring for a client newly diagnosed with gastroesophageal reflux disease (GERD). When preparing a teaching plan for the client, the nurse explains that the client should avoid caffeine for which of the following reasons? A) Caffeine increases acid production in the stomach. B) Caffeine causes distention of the stomach. C) Caffeine relaxes the lower esophageal sphincter. D) Caffeine decreases production of saliva
C
A nurse is caring for a client who is recovering from a hysterectomy with paralytic ileus. The client has no bowel sounds and has not passed flatus. Which of the following is a treatment priority for this client? A. The client should be prepped to return to the OR B. The client should receive oral fluids and pureed diet to stimulate the digestive tract. C. A nasogastric tube should be attached to intermittent or constant suction D. Bed rest should be encouraged
C
A nurse is caring for a client who is scheduled for an ileostomy. Which of the following interventions would be most helpful in preparing the client psychologically for the surgery? A. Include family members in preoperative teaching sessions. B. Encourage the client to ask questions about managing the ileostomy C. Provide a brief, thorough explanation of all preoperative and postoperative procedures D. Invite a member of the ostomy association to visit the client.
C
A nurse is caring for a patient who has excessive daytime sleepiness due to narcolepsy. Based on the nurse's understanding of narcolepsy, which of the following nursing diagnosis is most appropriate for this patient? A) Self-care deficit related to inability to get out of bed in the morning. B) Impaired urinary eliminations related to inability to hold urine. C) Risk of injury related to drowsiness. D) Knowledge deficit related to use of tools for activities of daily living.
C
A nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which of the following is the priority question to ask the patient or caregiver? A. Have you eaten more high-fiber foods lately? B. Are your bowel movements soft and formed? C. Have you experienced frequent, small liquid stools recently? D. Have you taken antibiotics recently?
C
A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning? A. Coughing up sputum occasionally B. Coughing up thin, watery sputum after nebulization C. Decreased ability to clear airway through coughing D. Lung sounds clear only after coughing
C
An agency nurse is called to fill a staffing shortage at an unfamiliar facility. On arrival, the nursing supervisor tells the agency nurse that charting is limited to abnormal or significant findings. The agency nurse recognizes this form of documentation as which of the following? A. Focus Charting B. CORE charting C. charting by exemption D. PIE model
C
The low-pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what initial action? A. Administer oxygen B. Check the clients vital signs C. Ventilate the client manually D. Start cardiopulmonary resuscitation
C
The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy? A. The stoma extends 1/2 inch above the abdomen. B. The skin under the appliance looks red briefly after removing the appliance. C. The stoma color is a deep red purple. D. An ascending colostomy just delivers liquid feces
C
What is the appropriate way for a nurse to dispose of information printed out from a patient's electronic health record? A. Rip the pages up into small pieces and place the pieces into a standard trash can. B. Place all papers in the flip-top binder designated for that patient that is located in the nurses station on the patient care unit. C. Place papers with patient information in a secure canister marked for shredding. D. Burn documents with patient information in the steel sink located within the dirty supply room on the patient care unit.
C
Your client is complaining of having a bowel movement within 30 minutes after a meal and having abdominal distention, sweating, palpations, cramping, and syncope after a meal. Which nursing diagnosis is most appropriate? A. at risk for nutritional deficits related to dysphagia B. at risk for nutritional deficits related to anorexia C. at risk for nutritional deficits related to dumping syndrome D. at risk for nutritional deficits related to lactose intolerance
C
A nurse wakes a patient who reports that he was having a disturbing dream. Which sleep stage was most likely occurring before the nurse woke him up? A) Stage 2 non-REM sleep B) Stage 3 non- REM sleep C) Slow- wave sleep D) REM sleep
D
The nurse assists the primary health care provider with the removal of a chest tube. During the procedure, the nurse instructs the clients to perform which action? A. Inhale deeply B. Breathe normally C. Breathe out forcefully D. Take a deep breath and hold it
D
Which of the following items of documentation in a medical record are acceptable (select all that apply)? A. Give .5 mg hydromorphone q 4 hours prn pain B. Lispro insulin 20 u BID SQ C. Stage III decubitus ulcer 3 cm x 4 cm x 1 cm noted at sacrum D. Propranolol 40 mg po BID E. 5.0 units regular insulin for glucose >201mg/dL
C, D
A client is undergoing bowel surgery in the morning, and the nurse caring for this patient is instilling the prescribed cleansing enema. The client reports abdominal pain and cramping during the administration of the enema. Which of the following is the appropriate nursing action ? A. Tell the client the process is necessary but will only take a little longer B. Tell the client to take slow deep breaths C. Advance the tube 2 cm and continue the instillation D. Stop the instillation for 30 seconds before resuming at a slower rate
D
A nurse in the emergency department is caring for a 2-year-old in acute respiratory distress who is receiving oxygen via a mask but keeps trying to pull the mask off. The most appropriate intervention by the nurse will include which of the following? A. Administer a sedative to calm the child B. Restrain the childs hands C. Explain to the child the importance of keeping the mask on D. Encourage the mother to hold the child and sing to him
D
A nurse is assessing a patient with Crohn's disease who was admitted to the medical- surgical unit on the previous shift after a bowel resection and a colostomy. Which of the following findings is a priority for notifying the HCP? A) Edema of the stoma B) Mucus from the rectum C) Protrusion of the stoma above the abdominal wall D) Gray and dusky stoma
D
What is an example of intrapersonal conflict? a. a nurse disagrees with a physician's orders for a patient's pain medication b. a nurse feels helpless when other nurses do not step in to assist her with a heavy workload c. a nurse opposes a charge nurse's instructions to set up equipment for a procedure d. a nurse wants to apply for a management position but feels as if she already spends too much time at work
D
Which of the following documentation entries is most accurate? A. "Patient walked up and down hallway with assistance, tolerated well." B. "Patient up, out of bed, walked down hallway and back to room, tolerated well." C. "Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk." D. "Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise. HR 94 and regular following exercise."
D
Which of the following is the best way to validate effective nurse-client communication? A. Conferences of the healthcare team B. Physiological changes of the client C. Medical assessment by the healthcare provider D. Feedback from the client
D
