NUR 112 PrepU
A client states, "I have abdominal pain." Which assessment question would best determine the client's need for pain medication?
"What does the pain feel like?"
The nurse offers a client items to perform oral care before breakfast. The client refuses the care, stating, "I prefer to brush my teeth after my meal." Which of the following statements by the nurse is most appropriate?
"I will note on your chart that you prefer oral care after meals."
A client twists his right ankle while playing basketball and seeks care for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which client statement suggests that ice application has been effective?
"My ankle looks less swollen now."
A nurse administers cefazolin instead of ceftriaxone to an 8-year-old with pneumonia. The client has suffered no adverse effects. The nurse tells the charge nurse of the incident but fears disciplinary action from reporting the error. The charge nurse should tell the nurse:
"Reporting the error helps to identify system problems to improve client safety."
The nurse gives a client 0.25 mg of digoxin instead of the prescribed dose of 0.125 mg. What action should the nurse take after realizing the mistake?
Assess the client and notify the physician.
Which actions by the nurse will most likely ensure that the correct client receives a medication? Select all that apply.
-Check the name on the armband with the name on the medication. -Compare the date of birth on the client's medical record to the date of birth on the client's armband.
The physician orders 2 teaspoons of an oral laxative as needed for a constipated client. How many milliliters should the nurse administer to the client?
10
Check the name on the armband with the name on the medication. Compare the date of birth on the client's medical record to the date of birth on the client's armband.
4" (10 cm)
What does the Code of Ethics for Registered Nurses include?
A code of ethics that states the nurse's obligation and responsibility to the client.
The client has just returned to bed following the first ambulation since abdominal surgery. The client's heart rate and blood pressure are slightly elevated; oxygen saturation is 91% on room air. The client reports being "a little short of breath," but does not have dizziness or pain. The nurse should first:
Allow the client to rest for a few minutes, then re-assess.
A nurse prepares to administer medication by the buccal route. Where should the nurse place this medication?
Between the client's cheek and gum
The nurse is administering prednisone to a preschool child with nephrosis. What should the nurse do to ensure that the nurse has identified the child correctly? Select all that apply.
Check the child's identification band against the medical record number. Verify the date of birth from the medical record with the date of birth on the client's identification band.
A nurse is administering indomethacin to a neonate. What should the nurse do to ensure that the nurse has identified the neonate correctly? Select all that apply.
Check the neonate's identification band against the medical record number. Verify the date of birth from the medical record with the date of birth on the client's identification band.
A nurse is assessing a postoperative client. Which information should the nurse document as subjective data?
Client's descriptions of pain
Why would a nurse be interested in a client's dietary history when administering drugs?
Dietary intake can alter the effectiveness of some drugs.
The nurse is performing a surgical dressing change and drops a sterile gauze on the bedside table outside of the sterile dressing tray's field. What would be the most appropriate action of the nurse?
Discard the gauze and use another sterile piece.
Two nurses are working the night shift on a medical unit. The first nurse completes an initial shift assessment on assigned clients. One hour later, the second nurse finds the first nurse asleep in the lounge. The first nurse remains asleep for the next 4 hours and then wakes up to do client rounds. What should the second nurse do in this situation?
Discuss the situation with the first nurse, including the safety implications of sleeping on the job.
A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure?
Over the client's thigh
Which statement is a guideline to help nurses protect themselves from liability?
Practice within the scope of the nursing standards of practice..
A nurse manager is auditing the nursing unit's adherence to infection control practices. Which of the following observations causes the nurse manager to be most concerned that the clients on the unit are at risk for infection?
Hand hygiene is forgotten between clients by several nurses on the unit.
A physician has ordered penicillin G potassium I.V., for a client with a severe streptococcal infection. A nurse determines that the client may be allergic to penicillin. When considering best practice, what should the nurse's priority intervention be?
Holding the penicillin G potassium and notifying the physician that the client may have an allergy to penicillin
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 intercostals space left mid-clavicular line
The nurse ascertains that there is a discrepancy in the records of use of a controlled substance for a client who is taking large doses of narcotic pain medication. What should the nurse do next?
Notify the nursing supervisor of the clinical unit.
A nurse needs to measure the pulse of a client admitted to the healthcare facility. Which site would the nurse most likely use?
Radial
A physician writes an order for a nurse to administer an IV medication which, according to the hospital policy, is not a nursing protocol. The nurse informs the physician that it is not a nursing protocol, and the physician states, "Give it, and I will cover you." What should the nurse do in this situation?
Refuse to administer the medication.
A nurse is teaching a client about a newly ordered drug. What could cause an elderly client to have difficulty learning about ordered medications?
Sensory deficits
A nurse says she's forgotten her computer password and asks to use another nurse's password to log on to the computer. Which response by the coworker demonstrates safe computer usage?
Telling the nurse that she may not use the password
The nurse notes that which statement concerning informed consent is true?
The client must be fully informed regarding treatment, tests, alternative treatments, and the risks and benefits of each.
A nurse has been teaching a client how to use an incentive spirometer that he must use at home for several days after discharge. Which client action indicates an accurate understanding of the technique?
The client takes slow, deep breaths to elevate the spirometer ball.
Which concept refers to a professional nurse's role in client advocacy?
The nurse promotes and protects the client's interests and rights.
A non-English-speaking client with chest pain has been admitted to the health care facility. Because the assigned nurse does not know the client's language, what would be the most appropriate solution in this case?
The nurse should request the help of a professional interpreter.
After completing initial assessment rounds, which client should the nurse discuss with the health care provider (HCP) first?
a client who was admitted from the emergency department last evening after a blow to the head who is now vomiting and confused as to time and place
A client in a hospice program has increasing pain. The nurse and client collaborate to schedule analgesics to provide:
around-the-clock routine administration of analgesics for continuous pain relief.
A client who's a member of Jehovah's Witnesses refuses a blood transfusion based on his religious beliefs and practices. His decision must be followed based on which ethical principle?
autonomy of the client
When assessing for oxygenation in a client with dark skin, the nurse should examine the client's:
buccal mucosa
The nurse is to administer ampicillin 500 mg orally to a client with a ruptured appendix. The nurse checks the capsule in the client's medication box, which is located inside of the client's room. The dosage of the medication is not labeled, but the nurse recognizes the color and shape of the capsule. The nurse should next:
contact the pharmacy to bring a properly labeled medication.
A client has a soft wrist-safety device. Which assessment finding should the nurse investigate further?
cool, pale fingers
A nurse pulls the curtains before changing the dressing of the surgical wound on the abdomen of a post-surgical client. What value is served?
dignity
An unconscious client with multiple injuries arrives in the emergency department. What should the nurse do first?
establish an airway
A charge nurse asks a newly graduated registered nurse (RN) who normally works on a medical-surgical nursing unit to take care of two clients in the coronary care unit. The nurse has not had experience with taking care of clients on monitors or using the medications that these clients are taking. The new nurse should:
explain to the charge nurse about his or her level of experience and express concerns about this assignment.
An elderly client has been admitted to the medical-surgical unit from the postanesthesia care unit. While the nurse is off the floor, the client falls out of bed and fractures his right leg and right wrist. The nurse finding him states, "The side rails were down and the bed was in the high position." The client's family files legal charges against the nurse and the hospital. Which charge most accurately reflects the nurse's actions?
negligence
To evaluate a client's reason for seeking care, a nurse performs deep palpation. What is the nurse assessing?
organs
A client hasn't voided since before surgery, which took place 8 hours ago. When assessing the client, a nurse will:
palpate the bladder above the symphysis pubis.
When assessing a client's pain, which is the most reliable indicator of the existence and intensity of acute pain?
the client's self-report
A nurse is teaching a group of nursing assistants about infection-control measures. The nurse tells the group that the first line of intervention for preventing the spread of infection is:
washing hands
