N210 Exam 3
A nurse is caring for a client undergoing IV therapy. The nurse knows that intravenous administration of medication is appropriate in which situation?
when the client has disorders that affect the absorption of medications
The nurse is promoting bedtime rituals with a family. Which statement indicates the nurse may need to provide further instructions to the mother?
"My boys love to rough-house in their room right before bedtime."
The home care nurse notices that the client only has a glass thermometer. What is the best response by the nurse?
"Would you consider using a digital thermometer?"
A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the nurse provide to the client?
"Dizziness when you change position can occur when fluid volume in the body is decreased."
The nurse is beginning to administer oral medications to a client. The client states, "I haven't taken that pill before. Are you sure it's correct?" The nurse rechecks the CMAR/MAR and finds that the medication is scheduled to be administered. Which response is most appropriate?
"Don't take that pill yet. I will verify that the medication was ordered by your primary care provider."
The 55-year-old client who is newly diagnosed with osteoarthritis of the hips asks the nurse why it hurts when walking. What is the nurse's best response?
"You have lost the padding in your joints and the friction causes pain."
The nurse is caring for a client with diabetes. Which client statement reflects that nursing teaching has been effective?
"I will eat a meal within a half hour of taking my morning insulin."
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 client with diabetes mellitus must monitor carbohydrate intake. Which client statement requires nursing intervention?
"My favorite drink is coffee with sugar."
A client is discussing vitamin and mineral intake with the nurse. Which client statement requires further nursing teaching?
"My husband and I are ordering a product that has megadoses of vitamins."
When taking the client's temperature, the student nurse will require further education when he states:
"The axillary route is the most accurate of all routes."
A client with gastritis who is taking aspirin for cardiovascular prophylaxis asks the nurse whether there is benefit in buying the enteric-coated product. What is the appropriate nursing response?
"The enteric coating will protect your stomach."
A student nurse asks the nurse what trochanter rolls are used for when providing client care. What is the appropriate nursing response?
"To prevent the legs from rotating outward."
A client with headaches has been told by the healthcare provider to increase intake of dietary magnesium. Which food will the nurse teach the client to consume?
whole grains
When assessing an infant's axillary temperature, it will be:
1°F (0.5°C) lower than an oral temperature.
A student nurse is preparing a presentation on sleep hygiene practices. What information should the nurse include? Select all that apply.
Eliminate caffeine intake 6 hours prior to bedtime. Do not watch television in bed. Use blackout or other types of curtains/blinds to keep the room as dark as possible.
Which contains all the components of a valid order?
John Smith, Atenolol 50 mg, twice a day, by mouth
The nurse is caring for four clients. The nurse recognizes that which client's lifestyle choice contributes most highly to risk for development of cardiometabolic syndrome?
28-year old who eats fast food daily
Drugs known to cause birth defects are called:
teratogenic
The primary reason for the Controlled Substances Act is:
to prevent drug abuse.
A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL (75 × 109/L) and a pulse of 78 beats/min. What number would the nurse document for this assessment?
5,850 mL (5,850 × 109/L)
The nurse is reviewing the plan of care for several clients who have prescriptions for intravenous medications. The nurse understands that which client is at the highest risk for greater effect of the IV medication?
73-year-old client diagnosed with liver disease
The nurse is performing a telephone follow-up with parents that she taught to monitor their newborn's BP and pulse at home. What results reported by the parents would indicate that the parents are performing the technique correctly and there is no cause for concern?
80/50 mm Hg and 145 bpm
A client is ordered 1000 mL 5% dextrose and normal saline to infuse over 12 hours. When setting up the electronic infusion device, the nurse would set the device to deliver how many milliliters of fluid per hour?
83
A nursing student is changing the client's bed. Which action requires intervention from the nursing instructor?
tossing soiled linen on the floor
The nursing student learns in Fundamentals that the primary purpose for using proper body mechanics is for which of the following reasons?
Acts to prevent injury to the client and/or nurse
A client reports periodic difficulty falling asleep. Which teaching will the nurse provide? (Select all that apply.)
Adhere to a regular schedule for waking and going to sleep. Go on a daily walk. Decrease caffeine intake.
At what period of life do nutrient needs stabilize?
Adulthood
A nurse is reviewing information about a prescribed drug in a drug handbook in preparation for administration to a client. When reading about the drug, the nurse identifies which name as the generic name?
Ampicillin sodium
A nurse documents a client's hemoglobin as 80 g/L. What nutritional condition does this biochemical data signify?
Anemia
A client has been in the hospital for the past 10 days following the development of an infection at her surgical incision site. Each morning the client reports overwhelming fatigue and has told the nurse, "I just can't manage to get any sleep around here." How should the nurse first respond to this client's statement?
Assess the factors that the client believes contribute to the problem.
The nurse is caring for a client who refuses most foods on the dietary tray. Which nursing intervention is appropriate?
Assess when client generally eats meals.
A nurse is assessing the respirations of a 60-year-old female client and finds that the client's breaths are so shallow that the respirations cannot be counted. What would be the appropriate initial nursing intervention in this situation?
Auscultate the lung sounds and count respirations.
A nurse is teaching a client about diabetes and glucose monitoring. What should the nurse include in the teaching?
Blood from the fingertips shows changes in glucose more quickly than other testing sites.
A nurse is caring for an older adult client who is admitted with failure to thrive to a medical surgical unit. Which laboratory value would the nurse expect to find with this diagnosis?
Blood urea nitrogen 15 mg/dL (5.35 mmol/L)
An athlete wants to increase her intake of complex carbohydrates and asks the nurse about potential sources. Which food is considered a complex carbohydrate?
Bread
A nurse on the night shift notices that a client is grinding his teeth while sleeping. How should the nurse document the diagnosis for the client?
Bruxism
Which client should not have a temperature assessed rectally?
Client with diarrhea
A nurse is administering a hepatitis B immunization injection to an adult patient. Which site would the nurse choose for this injection?
Deltoid muscle site
A client has smoked most of his life and has labored respirations. He is experiencing:
Dyspnea
Which activity would be appropriate to suggest to the client who reports having difficulty falling asleep every evening?
Eat some crackers with peanut butter at bedtime.
The nurse is working to increase functional ability with a client. Which assistive technique should be included in the plan of care?
trapeze bar
A nurse is preparing an injection by withdrawing the solution from a multidose vial. What is necessary to facilitate withdrawing a medication from the vial?
First, inject an equal amount of air into the vial.
A client who has been lying prone reports shortness of breath and a sensation of choking. Into which position will the nurse place the client?
Fowler's
A client will be ambulating for the first time since his cardiac surgery. What should the nurse consider when assisting this client?
If an ambulating client whom a nurse is assisting begins to fall, the nurse should slide the client down his own body to the floor, carefully protecting the client's head.
The pediatric nurse teaches parents about normal sleep patterns in their children. Which education point should the nurse include?
Inform parents that daytime napping decreases during the preschool period, and, by the age of 5 years, most children no longer nap.
A nurse at the health care facility is caring for an older adult client who complains of sleeplessness. Which condition is a manifestation of depression in an older client?
Insomnia
The nurse is teaching a new mother who is not breast-feeding her infant. What nutrient must be supplemented by the mother
Iron
A nurse can most accurately assess a client's heart rate and rhythm by which of the following methods?
Listen with the stethoscope at the fifth intercostal space left mid-clavicular line.
A nurse preparing medication for a client is called away to an emergency. What should the nurse do?
Lock the medications in a cart and finish them upon return.
A female client has developed an abscess following abdominal surgery, and her food intake has been decreasing over the past 2 weeks. Which laboratory finding may suggest the need for nutritional support?
Low serum albumin levels
For the last 3 weeks, a nurse in a long-term care facility has administered a sedative-hypnotic to a client who complains of insomnia. The client does not seem to be responding to the drug and is now lying awake at night. What is the most likely explanation?
Most sedative-hypnotics lose their effect after 1 or 2 two weeks of administration.
When a client tells the clinic nurse that he has irresistible sleep attacks throughout the day lasting from 10 to 15 minutes, the nurse suspects that the client may be experiencing what?
Narcolepsy
The nurse is caring for new parents. During her education session, the nurse instructs the parents on a newborn's sleep patterns. Which statement is accurate about a newborn's sleep patters?
Newborns sleep 16 to 17 hours per day.
The nurse manager is assessing the unit for proper work ergonomics. Which finding will require immediate intervention by the nurse manager?
Nurses and unit assistants use telephones with handsets.
The nurse places a client experiencing labored breathing in an upright position. The nurse notes that the client is able to breathe more easily in this upright position and documents this condition on the chart as:
Orthopnea
The nurse is preparing to assess a rectal temperature on an adult client. What is the appropriate nursing intervention?
Provide privacy for the client.
The nurse is caring for a client who is on bed rest and was just turned to the left side. Which action should the nurse take next to decrease the risk of impaired skin integrity?
Pull the shoulder blade forward and out from under the client.
The client is a 76-year-old who reports difficulty falling asleep and daytime drowsiness. Which figure best reflects REM and NREM cycles of this client?
Purple, awake most
The average dietary nutrient intake level that meets the nutritional requirement of almost all healthy people in a selected age and gender group is the:
RDA level
A nurse is caring for an adult with fever. The nurse determines that which site is most ideal for obtaining the client's core body temperature?
Rectum
The nurse is performing range-of-motion exercises on a client's arm. The nurse starts by lifting the arm forward to above the head of the client. Which action would the nurse perform next?
Return the arm to the starting position at the side of the body.
Which laboratory test is the best indicator of a client in need of TPN?
Serum albumin
A nurse is caring for a client with restless leg syndrome who complains of sleeplessness. Which of the following nursing diagnoses is most appropriate for this client?
Sleep Deprivation
A code is called and Nurse A hands several drugs to Nurse B, stating while rushing off, "Give these to my client while I help with the code." What is Nurse B's appropriate response?
State, "I cannot give medications for other nurses."
A client who has been receiving a secondary infusion of a new antibiotic for several minutes reporting itching and a sensation of throat tightness. What is the priority nursing intervention?
Stop the infusion of antibiotic.
The student nurse is providing an education program for preschool parents. The nursing student should include which intervention to improve the child's sleep?
The child should limit fluids after supper.
A nurse enters a client's room to check on his intravenous infusion. An electronic infusion device is not being used. When checking the solution container and rate, the nurse notes that that fluid is infusing at a rate slower than intended. When assessing the client, which finding would the nurse identify as most likely contributing to the slowed rate of infusion?
The client is resting his arm with the IV on his head.
The charge nurse is observing a new nurse care for a client who is receiving a continuous feeding through a nasogastric feeding tube. Which actions by the new nurse would require intervention by the charge nurse?
The new nurse places the client in the left lateral recumbent position.
The nurse is preparing to administer a transdermal medication. How should this be accomplished?
The nurse should apply the medication directly to the skin.
Which client's blood pressure best describes the condition called hypotension?
The systolic reading is below 100 and diastolic reading is below 60.
A nurse is assessing the blood pressure of a client using the Korotkoff sound technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record?
There is an auscultatory gap.
A physician orders nutritional therapy administered via a central vein for a patient who cannot take foods orally. What is the term for this type of nutrition?
Total parenteral nutrition (TPN)
Which guideline does the nurse apply to discussion of sleep patterns with older adult clients?
Total sleep time decreases as the clients age.
A client is prescribed warfarin, an anticoagulant. When educating this client about potential diet and drug interactions, the nurse would caution the client about foods containing which nutrient?
Vitamin K
A nurse is administering an intramuscular injection to a client using the Z-track method. Which action should the nurse perform to prevent leaking and ensure sealing of medication in the subcutaneous and dermal layers of tissue?
Withdraw the needle and release taut skin immediately after injection.
A 70-year-old client is taking his own pulse at home. He is following the instructions provided by the nurse. He counts his pulse 62 times in one minute. What should he do next?
Write it down
The proper use of the principles of body mechanics:
acts to prevent injury to the client and/or nurse.
The client is scheduled for a polysomnography to determine if the client has obstructive sleep apnea (OSA). The nurse instructs the client to:
anticipate sleeping overnight at a health care center.
At what point should the nurse perform the first of the three checks of medication administration?
as the nurse reaches for the drug package or container
An ultrasonic Doppler is used for:
auscultating a pulse that is difficult to palpate.
When a client is lifted or held by a nurse, the additional weight becomes a part of the nurse's weight and should be:
balanced over the center of gravity.
The nurse is helping a client who eats a normal diet of 2000 calories daily to read a nutritional label on a box of cereal. Which nutrient does the nurse identify as appropriate for this client?
cholesterol less than 300 mg
A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse can anticipate that the digoxin will:
decrease the apical pulse.
Which activity for rest break should not be incorporated into care planning for clients to aid in healing and recovery?
drinking an 8 oz cup of a caffeinated beverage
The nurse is preparing a client to be turned in bed. In what position would the nurse place the client to begin this procedure?
lying flat
After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client to sit up on the side of the bed?
near the client's hip, with legs shoulder-width apart and one foot near the head of the bed
A nurse records a pulse rate of 170 beats/min on a client's flow chart. For which of the following age groups would this be considered a normal reading?
newborn
The nurse is assessing a client for sleep disorders. The initial step in sleep assessment is:
observe client's hours of sleep and review client's sleep diary.
The community nurse is educating client groups about nutrition. Which group does the nurse identify that will benefit most from nutritional counseling and intervention?
older adults living on a fixed income
When assisting a client from the bed into a wheelchair, the nurse assesses the client for signs of dizziness upon standing. For what adverse condition is the nurse assessing the client?
orthostatic hypotension
Which medications are dropped into the ear to treat ear infections or to soften and remove ear wax?
otic
The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk?
predisposition to renal calculi
Which clients, at risk for poor nutritional intake, would benefit from nutritional counseling from the nurse? (Select all that apply.)
pregnant teenagers people with substance abuse problems older adults living on fixed incomes
A nurse is conducting a home assessment of a 90-year-old male client with a history of several minor strokes that have left him with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply.
removal of clutter on the floor placing a nightlight in the bathroom and the hallways moving the bedroom to the ground floor
Which assessment data would cause the nurse to suspect sundown syndrome in a client?
repeating the same phrase in the evening
The nurse is assessing the client for muscle mass, tone, and strength. She determines that there is increased tone that interferes with movement. The nurse documents this finding as:
spasticity.
The pediatric nurse is caring for a 3-week-old infant. In which position will the nurse place the infant to sleep?
supine
The pediatric nurse is caring for a newborn infant. In which position will the nurse place the infant to sleep?
supine
The nurse is assisting a client with limited mobility to turn in bed. After successfully turning the client to the side, where would the nurse place an additional pillow?
supporting the client's back
