fundamentals

A nurse is planning weight loss strategies for a group of client who are obese. Which of the following actions by the nurse will improve the clients commitment to a long term goal of weight loss. A. attempt to increase the clients self motivation B. keep detailed records of each clients progress C. Test client learning after each teaching session D. Avoid discussing areas that might cause the client anxiety.

A. Attempt to increase the clients self motivation Rationale .... Motivation to lear is important in improving a clients commitment to achievement of health goal, as well as increasing the mouth and speed of learning.

A nurse on a medical surgical unit is admitting a client. which of the following information should the nurse document in the clients record first? A. Data collection for the client B. plan of care for the client C. Nursing interventions performed for the client D. Evaluation of the clients progress

A. Data collection Rationale... The nurse should apply the nursing process priory-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing action. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the clients status, she must first collect adjusted data from a client. Assassin or collecting additional dat will provider the nurse with knowledge to make an appropriate decision.

A nurse is collecting data for a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? A. Evaluate pedal pulses B. Obtaining a medical history C. Measure vital signs D. Ask the client if he is experiencing any pain in the leg

A. Evaluate pedal pulses Rationale... For a client who has decreased circulation in the leg, evaluating pedal pulses is critical in order to determine adequate blood supply to the foot. The nurse should apply the safety and risk reductio priority-setting framework when caring for this client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. This framework assigns priority to the factor posing the greatest threat is the highest priority. The nurse would use Maslow's Hearty of needs, the ABC priority-setting framework, or nursing knowledge to identify with risk poses the greatest threat to the client

A nurse is reinforcing teaching with a client who has heart failure about how to reduce his daily intake of sodium. which of the following factors is themes important in determining the clients ability to learn new dietary habits? A. The involvement of the client in planning the change B. The emphasis the provider placed on the dietary changes C. the learning theory the nurse uses to teach the dietary changes D. the extend of the dietary changes planned for the client

A. The involvement of the client in planning the change Rationale..... According to evidence-based practice, client involvement in planning dietary changes is the most important factor in the clients ability to learn new habits

A nurse is collecting data for a health history of a client who is postoperative and ha paralytic ileum. Which of the following finding should the nurse expect? A. Frequent bowel sounds with flatus B. Absent bowel sounds with dissension C. Hyperactive bowel sounds with diarrhea D. Normal bowel sounds with increased peristalsis

B. Absent bowel sounds with dissension Rationale... pralytic ileum is an immobile bowel. With this disorder bowel sounds are absent and the abdomen is distended.

A nurse is drawing blood for laboratory testing from a client that results in blood spill on her gloved hand. the client has no documented blood stream infection. Which of the following action should the nurse take ? A. Was the gloved hands and them throw the gloves away B. Prepare an incident report to document the event C. Carefully remove remove the gloves and follow with hand hygiene D. Ask the provider to order a blood culture to determine the risk of infection.

C. Carefully remove the gloves and follow with hand hygiene Rationale..... standard precautions require the use of gloves and hand hygiene in the care of all clients

A nurse is caring for an older adult client who is violent and attempting to disconnect her IV line. The provider prescribes soft wrist restraints. which of the following actions should the nurse take while the client is in restraints? A. Tie the restraints to the side of the rails B. Perform range of motion exercises to the wrist every 3 hours C. Remove the restraints at a time for a client who is violent or non compliant D. Obtain a PRN prescription for the restraints

C. Remove the restraints oe at a time Rationale.... the nurse should remove one restraint at a time for a client who is violent or noncompliant

A nurse is collecting data from a client who report abdominal pain. Further reading reveal the client has a temperature of 39 degree celsius , a hear rate of 105/min, a soft contender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurses priority. A. Heart rate of 105 B. Soft, contender abdomen C. Temperature D. Overdue menses

C. Temperature

A use on rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. which of the following techniques should the nurse use? A. stand toward the clients stronger side b. instruct the client o lean backward from the hips C. place the wheelchair at a 45 degree angle to the bed D. assume a narrow stance with feet 15 cm (6 inches apart

C. place the wheelchair at a 45 degree angle to the bed Rationale.. Position the wheelchair at a 45 degree angle allows the client to pivot, Lessing the about of rotation required

A nurse is preparing to perform oral care for a client who is unresponsive. Which of the following actions hold the nurse plan to take? A. place the client supine B. keeps both side rails up C. Raise the level of the bed D. Inspect the client mouth using a finger sweep

C. rains the level of the bed Rationale.... The nurse should raise the bed to allow for the use of proper body mechanics and reduce the risk of self-injury

A nurse is caring for a client who is in the terminal stage of cancer. which of the following action should the nurse take when she observes the client crying? A. Contact the family and ask them to stay with the client B. offer to call the clients minister C. sit and hold the clients hand D. Leave the room and allow the client o cry privately

C. sit and hold the clients hand Rationale.. Which this action , the nurse uses the therapeutic communication techniques of silence, touch, and offering of self to the client.

A nurse is cairn for a client sho is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. the nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. which of the following action should the nurse take? A. Turn on the machine every 15 min to measure the clients blood pressure B. Record only blood pressure readings needed for the 15-min intervals c. obtain a manual and automatic reading and compare them D. Disconnect the machine and measure the blood pressure manually every 15 min?

D. Disconnect the machine and measure the blood pressure manually every 15 min Rationale.... if the nurse questions the reliably of the monitoring equipment, a manual process should be used. Also, malfunctioning equipment can pose a safety risk of rate client, so it must be tagged and removed

A nurse is reinforcing preoperative teaching with a client who is scheduled for arthroplasty in the next month and might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following suggestions should the nurse make? A. Ask you. provider to prescribe epoetin before the surger B, you should take iron supplements prior to the surgery C, Request a family member donate blood for you C. Donate Autologous blood before the surgery

D. Donate autologous blood before the surgery Rationale.... Autologous blood transfusion if the collection and rein fusion of the clients own blood. With preoperative autologous blood donation, the blood is drawn from the client 3-5 weeks before an elective surgical procure and stored transfusion at the time of surgery. Autologous blood is the safest form of blood transfusion, exclusive use of a clients own blood eliminates exposure to transfusion-trnasmitted infection

A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room when the client states she no longer wants to have the surgery. which of the following action should the nurse take? A. Tell the client it is too late for her to change her mind because the surgery is already scheduled?d B. Telephone the operating room and cancel the surgery C. Inform the clients family about the situation D. Notify the provider about the clients decision

D. Notify the provider about the clients decision Rationale... Acting as the client advocate, the nurse hours support the client in her decision and notify the provider

A nurse is preparing to provide tracheostomy car for a client. Which of the following actions should the nurse take first? A. open sterile supplies and solutions B. stabilize the tracheostomy tube C. Don sterile gloves D. Perform hand hygiene

D. Perform hand hygiene Rationale.. According to evidence-based practice, the nurse would first perform hand hygiene before touching the client or performing any skills such as tracheotomy care. This is vital because contamination of the nurses hands is a primary source of infection

A nurse is obtaining the blood pressure in a clients lower extremity. Which of the following actions should the nurse take? Auscultate for the blood pressure at the dosages pedis artery B. Measure the blood pressure with the client sitting on the right side of the bed C. Place the cuff 7.6 cm 3 inches above the popliteal artery D. Place the bladder of the cuff over the posterior aspect of the thigh

D. Place the bladder of the cuff over the posterior aspect of the thigh Rationale.... This is the correct position for the nurse to place the bladder of the cuff when measuring a lower extremity blood pressure

A nurse is auscultating the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse heard a high pitched secretions sound with the diaphragm of the stethoscope place at the their intercostal space of the left sternal border. which of the following heart sounds should the nurse document? A audible click B. murmur c. Third heart sound D. pericardial friction rub

D. pericardial friction rub

A nurse is reinforcing teaching with a gourd of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective? A. I should expect my heart rate to take longer to return to normal after exercise as I ge older B. Urinary incontinence is something I will have to live with as I grow older C. I can expect to have less ear wax as I get older D. my stomach will empty more quickly after meals as I grow older

A. I should expect my heart rate to take longer to return to normal after exercise as I get older Rationale... Older adults experience decreased cardiac output, which causes increased pulse rate during exercise. However, the pulse rate also takes longer to return to normal after exercise

A nurse is receiving an ancient from the PACU who is postoperative following abdominal surgery. Which of the following action should the nurse take to transfer the client tromp the stretcher to the bed? A. Lock the wheel s on the bed and stretcher B. Instruct the client o raise his arms above his hear C. Elevate the stretcher 2..5 cm about the height of the bed D. Log roll the client

A. Lock the wheels on the bed and stretcher Rationalel... Locking the wheels prevents the client from falling to th fellow by not allowing the cart or bed to move apart or away from the client.

A urs is instrument an assertive personnel about proper hand hygiene. which of the following statement by the AP indicates an understanding of the teaching? A. There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands B. I will used cold water when I wash my hands to protect my skin for becoming too dry C. I will apply friction for t least 10 seconds while washing my hands C. After washing my hands I will dry them from the elbows down.

A. There are times I should use soap and water rather than an alcohol based hand rub to clean my hands Rationle.... while alcodhol based hand rubs are as effective as soap and water in providing proper hand hygiene. the center of disease control and prevention recommends washing hands with soap and water at certain times such, as when the hand are visibly soiled with dirt or body fluids.

A nurse is caring for a client who has the 1 diabetes medius and is resistant to learning self-injection of insulin. which of the following statement should the nurse make? A. tell me what I can do to hep you overcome your fear of giving yourself injection B. I am sure your provider will no pleased that you refuse to give yourself insulin injection C. Its okay. Im sure your partner will be able to learn how to give you the insulin injection D. You won't be able to go home unless you learn to give yourself insulin injection

A. tell me what I can do to help you overcome your fear of giving yourself injections Rationale... This response illustrates the therapeutic communication technique of clarifying and offering of self. It is important for the nurse to allow the client to express feelings and fear and to support the client in learning how to give the injections

A nurse is caring for client who has a terminal illness. The client asks several question about the nurse religious beliefs related to death and dying. Which of the following action should the nurse take? A. Change the topic because the client is trying to divert attention from the illness to the nurse B. Encourage the client to express his thoughts about death and dying C. Tell the client that religious beliefs are a personal matter D. Offer to contact the clients minister or the facility's chaplain

B. Encourage the client to express his thoughts about death and dying. Rationale.... the nurse should recognize the clients need to talk about impending death and should encourage the client to discuss his thoughts on the subject. This is the therapeutic technique of selecting. Depending on the situation, the nurse can also share some thoughts on this topic. Self- disclosure is a communication skill that can help open lines of communication when appropriate. If the nurse does not want to share personal beliefs, the communication skills of offering self and listening to the clients thoughts are appropriate

A nurse is collecting data from a client who has diarrhea and decreased urination for several days. which of the following actions should the nurse take to determine if the client is dehydrated? A. push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink B. Grasp a skin fold on the chest under the clavicle, realizes it, and note whether is springs back C. press the skin in the above the ankle for 5 seconds, release it, and note the depth of the impression D. Measure the skin fold thickness at the upper arm using a pair of calibrated skinfold calipers

B. Grasp skin fol on the chest under the clavicle, release it, and note wether it springs back Rationale.... the nurse should use this technique for collect dat on skin turgor. If the client has good turgor and is properly hydrated, the skin will immediately return to normal, which dehydration, the skin will remain tented. There nurse can also collect data on skin turgor by grasping skin fold on the back of the forearm

A charge nurse is observing a newly licensed nurse perform tracheostomy care of r a client . which of the following action by the newly licensed nurse requires intervention A. obtaining hydrogen peroxide for the tracheostomy care B. obtaining cotton balls for the tracheostomy care C. obtaining sterile love for the tracheostomy care d. obtaining a sterile brush for the tracheostomy care

B. Obtaining cotton balls from the tracheostomy care Rationale... Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing tracheal access. The charge nurse hold intervention for this action.

A nurse is assisting with planning a community campaign about seasonal influenza. Which of the following plans should be included as a secondary prevention strategy? A. Holding a community clinic to administer influenza immunizations B. Screening groups of older adults in nursing care facilities for early influenza manifestations C. Educating parents of young children about the dangers of influenza D. Finding rehabilitation programs for older adults who have complications from influenza

B. Screening groups of older adults in nursing care facilities for early influenza manifestations Rationale.... Screening older adults who have some manifestations of illness to determine if they have influenza is an example of secondary prevention. Secondary prevention is focused on preventing complications of illness of providing care to prevent illness from becoming severe

A nurse is planning to obtain the vital signs of a 2-year old child who is experiencing diarrhea and who may have a right ear infection. Which of the following routes should the nurses use to obtain the temperature? A. Rectal B. Tympanic C. Oral D. Temporal

B. Tympanic Rationale.. The temporal arter route, while not as accurate as the rectal route for obtaining a precise body temp, is non-invasis and can be used to obtain a temperature in a toddle who may have an ear infection and who is having diarrhe. The nurse should place the probe behind the ear if the client is diaphoretic, but should avoid placing it over an area covered with hair.

A nurse on a medical-surgical unit is caring for a client. which of the following action should the nurse take first when using the nursing process? A. identify goals for client care B. obtain client information C. document nursing care need D. evaluate the effectiveness of care

B. obtain client information

A nurse is reinforcing teaching of postoperative deep breathing and coughing exercises with a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client A. The client asks the nurse to repeat the instruction before attempting to exercise B The client reports severe pain C. the client asks the nurse how often deep breathing should be done after surgery D. the client tells tenures that this exercise will probably be painful after surgery

B. the client reports severe pain Rationale.. Client how is experiencing severe pain is not able to concentrate and therefore is not ready to learn a new activity

A nurse in oncology clinic is collecting data for a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing physchological distress? A. my parents are retired, and they have come to help out with our children B. I am going to ask my husband to go to counseling with me C. I keep having nightmare about my upcoming surgery D. my girlfriends bought me a nice wig

C I keep having nightmares about my upcoming surgery Rationale... the use should recognize that nightmares and sleep disturbances are manifestations of anxiety and post traumatic stress disorder. These indicate that the client is at risk for experiencing phsychological distress

A nurse is caring for a child who is postoperatively a tonsillectomy. Which of the following actions should the nurse take? A. Encourage the cild to cough frequently to clear congestion from anesthesia B. Place a heating pad at the Childs neck for comfort C. Administer analgesics to the child on a routine schedule throughout the day and night D. Provider the child with ice cream when oral intake is initiated.

C. Adrigster analgesics to the child on a routine schedule throughout the day and night. Rationale... To sooth the clients throat following tonsillectomy, the nurse should administer pain medication routinely around the clock. The nurse can provider the medication rectally or intravenously to avoid the oral route.

A nurse is reviewing adult cardiopulmonary resuscitation CPR with a a newly licensed nurse. which of the following steps should the nurse identify as the first response when performing car? A. call for assistance B. begin chest compressions c. confirm unresponsiveness D. give rescue breaths

C. confirm unresponsiveness

A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following action should the nurse take? A. measure the pulse using a doppler ultrasound stethoscake the puope B. Check the clients pedal pulses c. count the apical pulse rate for 1 full minute, and describe the rhythm in the chart D. take the pulse at each peripheral Sita and count the rate for 30 seconds

C. count the apical pose rat for 1 full min. and describe the rhythm in the chart Rationale... If the peripheral pulse is irregular, the nurse should osculate the apical pulse for 60 seconds to obtain an accurate rate. The nurse should document the irregularity in the clients medical record

A nurse on medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing techniques. A. The nurse washes each part of her hands with five strokes B. The nurse washes from the elbows down to the hands C. The nurse washes with her hands held higher than her elbows D. the nurse uses minimal friction when washing her hands.

C. he nurse washes with her hands held higher that her elbows Rationale.... The nurse who is performing a surgical hand washing techniques should wash with her hands held higher that the elbows to the water and soapsuds can drain away from the clean area toward the dirty area.

A nurse is reinforcing teaching with an older adult client who has constipation. Which of the following statement should the nurse include in the teaching? A. Drink a minimum of 1,000 milliliters of fluid daily B. Increase your intake of refined-fiber foods C. Sit on the toilet 30 minutes after eating a meal D. Take a laxative every other day

C. sit on the toilet 30 min after eating a meal Rationale... Increased peristalsis occurs after food enters the stomach. Sitting on the toilet 30 min after eating a meal, regardless of feeling the urge to defeat, is recommended method of bowel retraining to treat constipation

A nurse is caring for alpine thwo requires a chest x-ray. Prior to the client being transported for the procedure, which of the following action should the nurse take first? A. explain the X-ray procedure to the client B. help the clients into a wheelchair before the transporter arrive C. ask if the client has any questions D. identify the client using two identifiers

D. Identify the client using tow identifiers

A nurse at a screening clinic is collecting data for a client who reports a history of heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? A. Fifth intercostal space just medial to the midclavicular line B. second Intercostal space to the left of the sternum c. Fifth intercostal space to the left of the sternum D. second intercostal space to the right of the sternum

D. second intercostal space to the right of the sternum Rationale.... The aortic valve is locate in the second intercostal space to there right of the sternum. Aortic stenosis produces a mid systolic ejection murmur that can be hear clearly at the aortic area with the client leaning forward.

A nurse is witnessing client singing an informed consent form for surgery. which of the following describes what the nurse is affirming by this action? A. the client fully understands the provider explanation of the procedure B. the client has been informed about the risks and benefits of the procedure C. the nurse witnessed the provider explanation of the procedure D. the signature on the pareoperte concept form is the clients

D. the signature on the preoperative consent form is the clients

A nurse is caring for an older adult client who becomes agitates when the nurse requests that the clients dentures be removed prior to surgery. Which of the following responses should the nurse make? A. Its for your safety. Dentures can slip and block your airway during surgery B. you wouldn't want your teeth to be lost or broken during surgery, would you? C. The anesthesiologist requires everyone to remove their dentures D. what worries you about being without your teeth?

D. what worries you about being without your teeth? Rationale.... The response by the nurse is therapeutic because it validates the clients feeling of agitation and seeks a reason for it.

A nurse observes an assistive personnel preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP. A. The reading will be inaudible if the cuff is too small for the client B. The width of the cuff bladder should be 75 percent of the circumference of the clients arm C. As long as the cuff will circle the arm the reading will be accurate D. Using a cuff that is too small will result in inaccurately high reading

D.using a cuff that is too small will result in an inaccurate reading Rationale... Blood pressure cuffs come in varius sizes, and the correct size cuff is necessary to obtain a reliable measurement. Blood pressure reading can be falsely high if the cuff is too small for the client.

A nurse is collecting data for a client. Identify the correct sequence of steps used for data collection of the abdomen? auscultation percussion palpation inspection

Inspection auscultation percussion palpation Rationale.... The appropriate sequence for the nurse to perform the abdominal data collection is to inspect auscultate, percuss and then palpate. This sequence prevents altering the bowl sounds and causing false results. The appropriate sequence for any other data collection for an adult client is inspection, palpation, percussion, and auscultation