Fundamental exam 3 final
A nursing home has an increase in vascular catheter-related infections. Which measure might be instituted to reduce the incidence?
Re-educating care providers on best practices in aseptic technique
Which instruction will the nurse provide to the nursing assistive personnel when providing foot care for a patient with diabetes?
Report sores on the patient's toes
You are caring for a 65-year-old client who was diagnosed with clostridium difficile. You prepare to enter the client's room. What personal protective equipment (PPE) should employees and visitors don?
clean gloves and a gown AND bleach
At the local wellness fair, the nurse is asked to share information on healthy bowel routines. Included in this area is the topic of having healthy defecated. The nurse should include which point in the instructional materials?
slowly introduces fiber-rich foods into your diet.
A client is experiencing a pain level of 5 (0-10) after spraining an ankle. What type of pain is the client experiencing?
somatic pain originates in the skin, muscles, bone, or connective tissue. The sharp sensation of a paper cut or aching of a sprained ankle are common examples of somatic pain.
What strategy is most effective in blocking the transmission of microbes from the infectious reservoir to susceptible hosts?
sterilizes the entire infectious.
The nurse is preparing to take vital signs in an adult client receiving continuous oxygen by mask. What is the best method used to assess the client's temperature?
. Axillary
A client is ready for a mastectomy and voices anxiety to the nurse. The nurse responds, "My mom had this surgery, you will be fine there is nothing to it." This is an example of what type of inappropriate communication technique
. Cliché
. In which phase of the nursing process does the nurse identify the patient's strengths and problems?
. Diagnosing
A client hospitalized with pneumonia begins having 5-6 loose to watery stools daily after initiating antibiotics. What nursing diagnoses would be appropriate for this patient pertaining to assessment of elimination?
. Diarrhea related to adverse effects of pharmaceutical agents.
The nurse is assessing a comatose client. Which objective assessment finding might indicate that this client is experiencing pain?
. Heart rate 115 beats/min
A nurse is caring for a client with diarrhea for 3 days. What findings should the nurse anticipate?
. Hyperactive bowel sounds over 30 sounds per minute.
. A nurse instructing a diabetic client on foot care. What statement by the client indicates the need for more education?
. I will not use any lotion on my feet
. A client is receiving post-operative epidural analgesia. What complication of epidural analgesia is the nurse most concerned with?
. Respiratory depression
A female resident in a long- term care facility is embarrassed about her incontinence. What nursing intervention could aid in meeting the goal of reducing incontinence episodes?
. Teach the patient Kegel exercises at regular intervals daily.
What nursing interventions are appropriate for a client who is receiving oxygen by nasal cannula?
. The oxygen should be humidified if the administration rate is greater than 4L/min
A nurse is changing the stoma appliance on a patient's ileostomy. Which characteristic of the stoma would indicate anemia?
. The stoma is a pale pink color.
A nurse enters a new order using military time (24hour clock). An order entered for 2200 (or 2000 will be 8pm) (2300 will be 11pm) converts to what time?
: 10:00pm
. Which of the following is a healthy mechanism of coping with stress of an illness?
: Attending support groups
What are the evaluative criteria used in evaluating the patient plan of care?
: Patient outcomes from the plan of care
Which of the following age-related changes place an older adult at risk for a UTI?
: incomplete emptying of the bladder.
The nurse is assessing a client a continuous opioids infusion, for which situation would the nurse immediately notify the primary care provider?
A pasero scale sedation level of 4
Which of the following complementary and alternative therapies consists of placing very thin needles at a particular point to restore the balance of yin and yang?
Acupuncture
Which of the following is the site of gas exchange?
Alveoli
which nursing intervention would be appropriate for preventing urinary tract infection?
Answer: Perineal cleaning after each incontinent episode
The client who is bed-bound complains of lower abdominal pain and pelvic pressure. Bowel sounds are present in all four quadrants and last bowel movement was yesterday. What should be assessed next?
Ask the patient when they last voided.
A client fell 6 hours ago. When the nurse enters the room to turn the client, the nurse notes that the client is restless and grimacing. What should the nurse do next in this situation?
Assess to determine the cause of the grimacing
You are caring for a 49-year-old client in an acute care facility. Your client recently had an increase in blood pressure. The baseline blood pressure was 110/68 and the client now has a blood pressure of 200/110. You determine that you need to call the provider. Which information will be provided as the "B" in the ISBARR communication technique?
Blood pressure of 200/110
A nurse obtained a client's respiratory rate and found the rate to be below 10 breaths per minute. The nurse document these findings as:
Bradypnea
What adventitious breath sound is heard on inspiration and often described as bubbling, crackling, or popping?
Crackles
What is a sign or symptom of late hypoxia?
Cyanosis
what medical procedure removes devitalized tissue and foreign material in a wound? Was reworded as - what medical procedure removes necrotic tissue in a wound?
Debridement
What is a priority nursing diagnosis that refers to Maslow's physiological needs?
Decreased cardiac output. ... IMPAIRED GAS EXHANGE
Which of the following is not a primary role of the nurse?
Diagnostician
Which statement best identifies when the nurse should begin discharge planning?
Discharge planning will begin upon the client's admission to the facility
A client complains the analgesic medication they take is no longer effective in controlling the pain. The nurse recognizes the client may be experiencing.
Drug tolerance
The nurse is caring for a patient on the medical-surgical unit who is experiencing an exacerbation of asthma. Which intervention will be most appropriate to help this patient sleep?
Elevate the head of bed at night
Nurses play an important role in facilitating sleep and rest for their clients. What intervention can the nurse include in a care plan for a sleep deprived client?
Eliminate use of caffeine, tobacco, and alcohol.
A client has an open wound from a left great toe amputation. Within one week, the nurse observes the wound bed is beginning to accumulate a thick yellow covering with watery drainage. How would the nurse document this?
Epithelia tissue covering wound bed with purulent drainage.
A nurse is working with a client newly diagnosed with colon cancer. The nurse may coordinate the care by which of the following actions? (Select all that apply)
Explaining diagnosis procedure . Providing preoperative education. e. Supporting client and family.
A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following pieces of personal protective equipment (PPE) should the nurse remove first?
Gloves
The nurse is reviewing with the client their health promotion activities. Which of the following client activities would the nurse document as primary health promotion activity?
Hepatitis B vaccine
Which statement by the nurse indicates a correct understanding of documentation?
I should chart as soon as possible after nursing care is given Choosing outcomes for the client
How does the development of Quality and Safety Education for nurses (QSEN) improve nursing education outcomes?
QSEN teaches the knowledge, skills, and attitudes necessary to improve the quality and safety of healthcare systems.
What information is omitted from a nurse's narrative note?
Interpretations of patient's pathology
The -------- is the most commonly transplanted organ?
KIDNEY
What is not part of the infection cycle?
Length of exposure
A nurse is caring for a postoperative patient who is experiencing pain. Which complementary and alternative therapy involves client participation by the patient and is appropriate for all levels of care?
MEDICATION
The family of a patient who has just died asks to be alone with the body and asks for supplies to wash the body. the nurse providing care knows the mortician usually washes the body. Which response would be most appropriate?
Provide the requested supplies, checking if this request is linked to their religious or cultural customs and asking if there is anything else you can do to help
Which of the following is true regarding the use of the incentive spirometer?
Provides visual reinforcement for deep breathing.
What oxygen device can deliver the highest concentration in the spontaneously breathing client?
Nonrebreather mask: the NRB allows for the delivery of higher concentrations of oxygen.
You are caring for a client who is recovering from a knee replacement surgery. Your nursing diagnosis is "impaired mobility". Which of the following is an appropriate outcome/goal for this client
Nursing will help the client ambulate 50 feet TID within 24 hours.
You are caring for a 65year old client. Current vital signs are: 122/70, P: 67; RR 10; oxygen saturation 93%. Which of the following may be causing a decrease in this client's respiratory rate?
Opioid analgesic
Using the principles of standard precautions, the nurse would wear gloves in what nursing interventions?
Providing oral hygiene
The nurse knows that communication can occur by verbal or nonverbal methods. What are examples of non-verbal communication the nurse may observe in a client? (Select all that apply)
Posture silence Eye contact
A nurse is caring for a 34-year-old client who has an incision to her chin as a result of a bicycle accident. The wound was surgically closed using 8 sutures. This wound is healing by what process?
Primary intention
The nurse is caring for a patient who has a stage III pressure ulcer. Which type of healing will the nurse focus the care plan?
Secondary intention
A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?
Secure the restraints using a quick-release tie.
After repositioning a client on the left side, the nurse notices a reddened area over the coccyx. The area does not blanch when the nurse compresses it with thumb pressure. One hour later, the nurse reassesses the area and finds the redness remains and the skin is intact. How should the nurse document this area?
Stage I pressure ulcer
A client suddenly begins to feel light-headed and dyspneic. What objective data anticipate finding in the focused assessment?
Tachypnea: fast breathing
A client is receiving physical therapy following knee surgery. This is an example of what type of care.
Tertiary
How does a wound heal if initially left open for five days to allow an infection to resolve and then closed using sutures?
Tertiary intention: and third intention, in which the wound is left open for a number of days and then closed if it is found to be clean.
signs and symptoms of hyperglycemia
The 3 P's -polydipsia -polyphagia -polyuria
What nursing organizational statement defines the social context of nursing and the standards of professional nursing practice?
The ANA Nursing's social policy statement
A nurse working with a client in pain recognizes and avoids common misconceptions and myths about pain. In regard to the pain experience, which of the following is correct?
The client is the best authority on the pain experience
What is an appropriate outcome for a client who needs nursing assistance with voiding?
The client will empty the bladder completely at least every four hours while awake with nursing assistance.
A client has been admitted to a post-surgical unit with a patient-controlled analgesia (PCA) system. Which statement is true of this medication delivery system?
The dose that is delivered when the client actives the machine is preset
How would you describe the event when a coworker verbalizes that all members of the culture are the same?
The nurse is stereotyping a client.
A client visits the county health department for follow up on his management of pulmonary tuberculosis. What kind of assessment will the nurse perform?
Time-lapsed assessment
What is the priority reason ISBARR is used by nurses when giving hand -off report?
To accurately communicate client information.
Why is evidence-based practice essential for patient care?
To provide care based on scientific evidence.
The client reports having incontinence after surgery and that it is continuous and unpredictable. What type of incontinence is client describing?
Total incontinence
Complementary and alternative therapies can increase quality and length of life when integrated with traditional medicine. Which nursing intervention best represents the use of integrative care?
Using guided imagery and herbal tea to relax a patient before bed
Which of the following lung sounds would be expected in a healthy, adult client
Vesicular
The nurse is assessing a heel pressure injury on a client. Objective data reveals an ulcer that is 3cm x 4 cm x 0.5cm and involves the epidermis, dermis, subcutaneous tissue, and exposed muscle. The wound bed is red and moist. The nurse also notes an area where the wound extends laterally under the skin 3cm. what would the nurse document this wound as?
a. A stage IV pressure ulcer with granulation tissue and undermining
. A nurse is caring for a client who is being prepared for discharge after having abdominal surgery with placement of a colostomy. What patient education should the nurse carry out? Select all that apply
a. Appliance application c. Signs and symptoms of bowel obstruction d. skin assessment of the skin surrounding the stoma e. odor prevention f. Follow-up physician care
What are signs and symptoms of hypoglycemia? Select all that apply
a. Diaphoresis (sweating) c. shakiness e. confusion
A post-operative client with a sutured abdominal incision felts a sharp abdominal pain after having a bowel movement. Upon inspection, the nurse notices there is bowel (intestines) protruding from the incision site. What is this complication referred to?
a. Evisceration
Upon evaluation of the outcomes/goals set in the care plan for your client, you determine that the client is unable to meet the outcome/goal. What may you change in the original care plan? (Select all that apply)
a. Modify the interventions. b. Modify the outcome to be realistic. c. Adjust time criteria in outcome
Which of the following are culturally sensitive considerations? (Select all that apply)
a. Recognizing that culture is an important component of individuality. b. Recognizing that each person holds various beliefs about pain. c. Respecting patient's right to respond to pain in their own manner. d. Learning the primary cultural and health practices of the dominant cultures. f. Allowing people of different cultures the right to worship as they please.
You are providing care for a client who is unable to move the right side of their body due to a stroke. You create a plan of care to include which types of passive and active range of motion (ROM)
a. Right side PROM; left side AROM
What practices must be followed when performing passive range of motion (PROM) on a client? Select all that apply?
a. The nurse moves the client's joint through its range of motion. b. PROM improves joint mobility and increases circulation. e. Friction to the skin must be minimized when performing PROM
What are modifiable risk factors for cardiopulmonary function? Select all that apply.
a. obesity d. cigarette smoking e. occupational exposure to asbestos
A hospitalized client is being woken up every hour during the night for care and procedures. The nurse realizes that the lack of sleep can have which physiological effect?
a. reduced metabolism
What is included in the list of professional nursing values (select all that apply)
a. social justice b. Altruism c. Autonomy d. Integrity
The client's white blood cell count (WBC) is 6,500/mm3. What interpretation of the laboratory values by the nurse is most accurate?
b. Client value is within normal range
When providing skin care for elderly, what age-related changes should be considered in order to provide the best patient centered care and prevent injury?
b. Decrease elasticity of the skin
A nurse is reviewing a client's chief complaint and reads "urge incontinence ". Based on this information, the nurse will assess which system?
b. Genitourinary (GU)
You are interviewing a patient who is on continuous oxygen for chronic lung disease. He stops speaking several times to catch his breath. What statement by the patient is most concerning and would require the nurse to intervene?
b. I smoke in the house because it is too hard to breath outside in the cold
. You are a nurse working in a sub-acute rehabilitation hospital. Several of the clients have orders for straight catheterization every 4 hours. You question whether frequent straight catheterization can increase the risk for urinary tract infection (UTI) compared to inserting an indwelling catheter. You began by formulating a PICO question. Which of the following will the "O" in your PICO question refer to?
b. Incidence of UTI
What strategy is proven effective in blocking the transmission of microbes from contaminated food (reservoir) to immunocompromised patients (susceptible hosts)?
b. Restrict fresh, unwashed produce for immunocompromised patients.
Which of the nursing interventions will help to promote the client's physical comfort related to stoma care?
b. keeps the skin around the stoma site moist
. What is the primary purpose of the client's medical record?
c. To foster the client's continuity of care through communication across settings
A nurse is caring for a patient with a new ileal conduit. Which nursing diagnosis would be most appropriate?
c. Disturbed body image
You are assessing the pulse in a client prior to administering a medication that may cause bradycardia. Which is the best method for assessing this client's pulse?
d. Assess the apical pulse
This was changed in in my exam to, A client visits an urgent care facility with a chief complaint of shortness of breath, cough, and fever. What should the nurse perform.
focused assessment.
A nursing diagnosis statement does not include what item?
medical diagnosis
What is not one of the four categories of infections responsible for the majority of healthcare associated infections
methicillin resistant staphylococcus aureus MRSA
The nurse assigned to a client is most concerned with which of the following assessment findings?
urine output of 25ml/hr
Which instruction should the nurse give to the client when a stool specimen is collected?
void first so the stool sample does not contain urine (Void before the specimen is collected)
