NUR 155 Exam 4
In preparation for cataract surgery, the nurse is to administer prescribed eye drops. The nurse reviews the primary health care provider's prescriptions, expecting which type of eye drops to be prescribed?
A mydriatic medication
The nurse is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse should take which action?
Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication
The nurse is preparing to administer an intramuscular injection of pain medication to a new postoperative client. When the nurse walks into the client's room, the client asks why he is receiving an intramuscular form of the medication instead of the oral form. What is the nurse's best response with regard to the absorption of the medication?
Medications given this way are absorbed more quickly than by other routes
The nurse is planning to conduct a physical assessment with a client from a different culture. What is the best way for the nurse to show cultural sensitivity when addressing the personal questions required of the nursing history?
break the assessment into shorter intervals and discuss general topics first
The nurse is explaining a preoperative teaching plan to an English-speaking client. What are some other aspects of verbal communication? Select all that apply.
timing, volume, voice tone, ability to share thoughts and feelings
The prenatal clinic nurse is performing an assessment on a culturally diverse client. Besides conversational style, what are some of the most important cultural and communication considerations the nurse must be aware of? Select all that apply.
touch, eye contact, personal space, time orientation
The nurse is preparing to administer an intradermal medication. Which action should the nurse take before administering the medication?
Cleanse the site of injection with an alcohol swab and wait for the alcohol to dry
The nurse is providing instructions to a client who will be self-administering eye drops. To minimize systemic absorption of the eye drops, the nurse should instruct the client to take which action?
Occlude the nasolacrimal duct with a finger after instilling the drops
Betaxolol eye drops have been prescribed for a client with glaucoma. The nurse monitoring this client for side/adverse effects of the medication would place highest priority on which assessment?
Pulse rate
A client has requested that she have a special item present in her room and explains that it gives her a feeling of comfort and a sense of organization. On which psychosocial component is this client focusing?
Religion
The nurse is preparing to administer an oral medication to an infant. In which position should the nurse place the infant? *Prone *Semi-Fowlers *Trendelenburg's *Dorsal recumbent
Semi-Fowler's
Which most essential element should the nurse consider to promote client adherence to care recommendations?
Adhering to the client's cultural preferences
What elements are essential for the nurse to address to be able to deliver culturally competent care? Select all that apply.
Assessing the client's health preferences, Having knowledge of various racial and ethnic groups, Acknowledging personal misconceptions of various ethnic groups, Recognizing that subcultures exist and not every characteristic of the cultural group is present
The nurse manager is concerned that a staff nurse provides client care with a cultural prejudice. Which situation did the manager observe to come to this conclusion?
Bringing previous negative information and experiences into this situation
A miotic medication has been prescribed for the client with glaucoma, and the client asks the nurse about the purpose of the medication. Which response should the nurse provide to the client?
The medication causes the pupil to constrict and will lower the pressure in the eye
A client has a prescription to receive purified protein derivative, 0.1 mL, intradermally. The nurse should administer the medication by using a tuberculin syringe according to which guidelines?
26-gauge, 5/8 inch needle inserted almost parallel to the skin, with the bevel side up
A client is prescribed an eye drop and an eye ointment for the right eye. How should the nurse best administer the medications?
Administer the eye drop first, followed by the eye ointment
The nurse is teaching a client from a culture that is present oriented about a dressing change that should be performed twice a day. How should the nurse address the cultural issue?
Instruct the client to change the dressing after breakfast and before going to bed
The preoperative medication sheet identifies that cyclopentolate is prescribed for a client before cataract surgery. The client asks the nurse what the medication is for, and the nurse provides education. Which statement by the client indicates that teaching has been effective?
It paralyzes the muscles in my eye
Before a client goes to surgery, he requests to have his spiritual leader present and pray over him. According to the HEALTH traditions model, which traditional method is the client invoking?
Restoring HEALTH
An older client is seen in the clinic for a physical examination. Laboratory studies reveal that the hemoglobin and hematocrit levels are low, indicating the need for further diagnostic studies and a blood transfusion. The client is a Jehovah's Witness and refuses to have a blood transfusion. The nurse should take which most appropriate action?
Support the client's decision not to receive a blood transfusion
A client with glaucoma is receiving acetazolamide. The nurse educator provides education to a group of nurses about the indications for and effect of this medication. Which statement by one of the nurses indicates that the teaching has been effective?
This works to decrease introccular pressure
The nurse prepares to administer an intramuscular injection to a 4-month old infant. The nurse selects which best site to administer the injection? *Ventrogluteal *Lateral deltoid *Rectus femoris *Vastus lateralis
Vastus lateralis
The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history and determines it is necesssary to contact the PCP if the client is also taking which medications? Select all that apply
Warfarin, Glimepiride, Amlodipine
The nurse is caring for a non-English-speaking client and is attempting to integrate the client's cultural practices into Western medicine. What are some other aspects of culturally competent care the nurse can employ? Select all that apply.
increasing client safety, using spiritual practices, reducing health disparities, increasing client satisfaction, preventing misunderstandings between the nurse and the client
The clinic nurse is caring for a client who has been prescribed fentanyl, a potent opioid, for chronic pain. In what forms is it available for chronic pain administration in the at-home setting. Select all that apply
intranasal spray, oral transmucosal lozenge, 72-hour transdermal patch, effervescet buccal oralets
A non-Englishspeaking client needs to have an emergency surgical procedure. The hospital has an interpreter available. When the INT arrives to explain the procedure and help with the consent form, the nurse provides the best support when
requesting that the INT translate, as closely as possible, the same words used by the staff
A new graduate nurse is working in a busy emergency department of a hospital, situated in a culturally diverse area of the city. In striving to be culturally sensitive, what should the nurse do?
try to learn about the attitudes toward health care and traditions of the different cultures in that area
A client who had abdominal surgery is receiving epidural analgesia. The nurse monitors the client closely, knowing that which is a potential complication of this therapy?
Dislodgment of the epidural catheter because the catheter is not sutured in place
An antihypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse that he would like to take an herbal substance to help lower his blood pressure. The nurse should take which action?
Encourage the client to discuss the use of an herbal substance with the PCP.
The nurse is preparing a plan of care for a client and is asking the client about religious preferences. The nurse considers the client's religious preference as being characteristic of a Jehovah's Witness if which client statement is made?
I cannot have any food containing or prepared with blood
The nurse is providing medication instructions to a parent. Which statement by the parent indicates a need for further instruction?
I should mix the medication in the baby food and give it when I feed my child
When teaching a client with glaucoma about the effects of a miotic medication, the nurse should tell the client that the medication will produce which effect?
Lower intraoccular pressure and improve blood flow to the retina
A client makes the following statement: I must be paying for all the wrongs I did in my life, to have such a diagnosis as this. The nurse suspects that this client views health from which type of belief?
Magico-religious belief
The nurse preparing a client for ear irrigation as prescribed by the pcp. Which action should the nurse take when performing the procedure?
Warm the irrigating solution to 98.6
The nurse would question the primary health care provider if which medication were prescribed for a client with glaucoma?
Atropine sulfate
A client is prescribed an eye drop and an eye ointment for the right eye. How should the nurse best administer the medications? *Administer the eye drop first, followed by the eye ointment *Administer the eye ointment first, followed by the eye drop *Administer the eye drop, wait 15 minutes, and administer the eye ointment *Administer the eye ointment, wait 15 minutes, and administer the eye drop
Administer the eye drop first, followed by the eye ointment
When communicating with a client who speaks a different language, which best practice should the nurse implement?
Arrange for an interpreter to translate
A female client is being discharged after a lengthy hospitalization. The family is from a male-dominated culture. Before discharge instructions are given, which action should the nurse take?
Arrange for teaching when the spouse is available
A new graduate nurse is moving from a small rural college town to a metropolitan area to begin work in a county hospital. The nurse has had limited prior experience with the various cultural groups that are served by the hospital. What might be this nurses greatest challenge?
Assimilation
The nurse is implementing the complementary therapy of therapeutic touch when caring for clients. The nurse should implement which action when performing therapeutic touch?
Position hands 2-4 in from the body
A client with glaucoma is given a prescription for a pilocarpine ocular system. The nurse plans to provide which instruction to the client on how to use the medication?
Check the eye each morning to make sure that they system is in place
A clinic nurse is performing an admission assessment on an African American client scheduled for cataract removal with intraocular lens implantation. Which question should the nurse avoid asking on the initial assessment?
Do you have any family problems?
Which is the best nursing interventions regarding complementary and alternative medicine?
Educating the client about therapies that he or she is using or is interested in using
A newly immigrated client is constantly attended to by family members. This has presented a problem to the nursing staff and the delivery of nursing care. In order to address this issue in a culturally sensitive manner, the nurse should take which action?
Evaluate the benefits of family participation in the clients care
The nurse is preparing a menu for a Jewish client who observes kosher customs. Which food items would be appropriate to serve this client, assuming all have been properly inspected and prepared?
Fish, vegetables, and hot tea
The nurse educator asks a student to list the 5 main categories of complementary and alternative medicine, developed by the National Center for Complementary and Alternative Medicine. Which statement, if made by the nursing student, indicates a need for further teaching regarding CAM categories?
Magnetic therapy and massage therapy are a focus of CAM
The nurse is preparing to administer a tuberculin skin test to a client via the intradermal route. Which action should the nurse perform when administering this test to the client? *Inject the medication and place a pressure dressing over the medication site *Make a circular mark around the injection site after administration of the tubreculin test *Administer the injection with the needle bevel facing downward at a 10 to 15 degree angle *Massage the area with an alcohol swab after injection to ensure that the medication is absorbed
Make a circular mark around the injection site after administration of the tuberculin test
The nurse plans care for an older client admitted with a fractured hip. Which analgesic prescribed by the primary health care provider at standard doses and frequencies would the nurse question?
Meperidine hydrochloride by IM route
The nurse is preparing medications for administration. In addition to the right medication, the nurse adheres to which additional rights of medication administration? Select all that apply *The right dose *The right route *The right time *The right client *The right staff member *The right documentation
The right dose, the right route, the right time, the right client, right documentation
The nurse is preparing to administer medication using a client's nasogastric tube. Which actions should the nurse take before administering the medication? Select all that apply.
check the residual volume, aspirate the stomach contents, turn off the suction to the nasogastric tube, test the stomach contents for a pH indicating acidity
A community health nurse is learning about the REACH initiative and has decided to implement community education on this approach. What topics should the nurse include in this education? Select all that apply *child and adult immunizations *cardiovascular disease *chronic lower respiratory disease *stroke *infant mortality
child and adult immunizations, cardiovascular disease, infant mortality
Betaxolol hydrochloride eye drops have been prescribed for a client with glaucoma. Which nursing action is most appropriate related to monitoring for side and adverse effects of this medication?
monitoring blood pressure
Betaxolol eye drops have been prescribed for a client with glaucoma. The home health nurse preparing to visit the client develops a plan of care that includes monitoring for the side/adverse effects of this medication by taking which assessment action?
monitoring body weight
A nurse educator uses Madeleine Leiningers model and describes a formal area of study and practice focused on comparative human-care differences and similarities of the beliefs, values, and patterned lifeways of cultures to provide culturally congruent, meaningful, and beneficial health care to people. What type of nursing is the educator practicing?
transcultural nursing
The nurse is admitting a client and knows that clients typically share information about herbal supplements or therapies only if they are specifically asked. What are some additional things the nurse needs to do when dealing with this topic with clients? Select all that apply.
use open-ended questions, respond to clients with comments that invite an open-minded discussion, document the use of any herbal products or dietary supplements in the client record, create an accepting and nonjudgemental attitude when assessing use of or interest in herbal products or dietary supplements
The nurse is caring for a pediatric client who is going to receive a vaccination. Place the nursing actions for performing this procedure in order of priority
verify prescription, assess for allergies, obtain parental consent, check lot number and expiration, select appropriate site and administer vaccine, provide vaccination record
The nurse is preparing to administer eye drops. Which interventions should the nurse take to administer the drops? Select all that apply
wash hands, put gloves on, place the drop in the conjunctival sac, pull the lower lid down against the cheekbone
The nurse has completed client teaching regarding medication administration. Which client statement best illustrates compliance?
I'm glad to know about my medications, it makes taking them a lot easier
A client has been prescribed betaxolol eye drops for the treatment of glaucoma. The ambulatory care nurse determines that the client understands proper medication use if the client states the need to return to the office for monitoring of what item(s)?
Blood pressure
The nurse is performing an admission assessment on a client who has a history of glaucoma and uses latanoprost eye drops. Which assessment finding would indicate a side/adverse effect of these eye drops?
Brown pigmentation of the iris
The home care nurse is reviewing the record of a client newly diagnosed with glaucoma who is scheduled for a home visit. The nurse notes that the primary health care provider (PHCP) has prescribed atropine sulfate and pilocarpine hydrochloride eye drops. The nurse should contact the PHCP before the home visit for which reason?
Clarify the prescription for the atropine sulfate
The charge nurse is educating a new nurse on culturally competent communication techniques. Which response(s) made by the new nurse indicates a need for follow-up? Select all that apply
I should use a language interpreter for all culturally diverse groups, I should recognize my own biases and address known stereotypes with the client
A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse that an interpreter is needed. Which is the best action for the nurse to take?
Page an interpreter from the hospital's interpreter services
The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client having expectoration problems because of chronic thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drainage the nurse will perform which action to help loosen secretions?
Percussion and vibration
The nurse is teaching a mother to instill drops in her infant's ear. The nurse explains that to give the ear drops correctly, the mother needs to take which action?
Pull down and back on the earlobe and direct the solution toward the wall of the canal
The nurse is providing care to a Hispanic client who is terminally ill. Numerous family members are present most of the time, and many of the family members are very emotional. What is the appropriate action?
Request permission to move the client to a private room and allow the family members to visit
A client is in the bathroom when the nurse arrives at his room with his scheduled medications. The client calls to the nurse, "Just leave my medication on the bedside table like the rest of the nurses, and I will take it when I get finished." What is the nurse's best action? *Tell the client that he or she will be back when he is finished *Leave the medication at the bedside as the client requested *Let another nurse who is not busy give the client his medication when he is finished *Tell the assistive personnel to give it to the client when he is finished
Tell the client that he or she will be back when he is finished
A community health nurse works with a variety of cultures providing health care services that include preventive care, acute treatment, and education. Of the following clients, which is the most likely to use folk medicine?
The client who speaks little English and does not have a job
A client who is scheduled for cataract surgery requires preoperative instillation of cyclopentolate eye drops as prescribed. The client asks the nurse why this medication is needed, and the nurse provides education. Which statement by the client indicates that teaching has been effective?
The medication dilates the pupil of the operative eye
The nursing student is assigned to care for a client with glaucoma for whom pilocarpine hydrochloride eye drops have been prescribed. The nursing instructor asks the student to describe the action of the eye medication. Which statement by the student indicates an understanding of the purpose of this medication?
The medication increases the blood flow to the retina and also will lower the pressure in the eye
The nurse is preparing to provide preoperative teaching to a Spanish-speaking client and the client's family. Which nursing action would be most effective for teaching the client?
The nurse secures the assistance of a professional interpreter to communicate with the client
The nurse is preparing to administer eye drops. Which interventions should the nurse take to administer the drops? Select all that apply. *Wash hands *Put gloves on *Place the drop in the conjunctival sac *Pull the lower lid down against the cheekbone *Instruct the client to squeeze the eyes shut after instilling the eye drop *Instruct the client to tilt the head forward, open the eyes, and look down
Wash hands, put gloves on, place the drop in the conjunctival sac, pull the lower lid down against the cheekbone
The community health nurse is using the Heritage Assessment Interview tool with a group of community members. Which data indicate heritage consistent? Select all that apply *a client frequently visits the old country neighborhood he grew up in *a client is raised by a single parent *the clients education occurred at a religious school *the client participates in religious festivals and cultural events *the client has been the first of his family to earn a college degree
a client frequently visits the old country neighborhood he grew up in, the clients education occurred at a religious school, the client participates in religious festivals and cultural events
The nurse teaching a mother how to administer ear drops to an infant tells the mother to pull the child's ear in which direction?
down and back and direct the solution toward the wall of the canal
A nurse is working with a home health client whose spouse was not born in the United States. During the home visit, the nurse realizes that the client has acquired the identity of her spouses culture and has adopted some of the health practices of that culture. Which process should the nurse identify as occurring with the spouse?
Assimilation
The nurse working in a long-term care facility notes that several clients are taking pilocarpine hydrochloride eye drops. The nurse ensures that which medication is available on the nursing unit for use if a client should develop systemic toxicity from pilocarpine hydrochloride?
Atropine sulfate
Which medication, if prescribed for the client with glaucoma, should the nurse question?
Atropine sulfate
A Chinese client is hospitalized with a fever of unknown origin and follows a very traditional, cultural view of illness. Which food should the nurse offer the client?
Cold liquids
In preparation for cataract surgery, the nurse is to administer cyclopentolate eye drops at 9:00 a.m. for surgery that is scheduled for 9:15 a.m. What initial action should the nurse take in relation to the characteristics of the medication action?
Consult the surgeon, as there is not sufficient time for the dilative effects to occur.
The nurse is annoyed by a healthy Hispanic American client who had minor abdominal surgery 2 days ago. The client claims he cannot get out of bed by himself, and the nurse lectures the client and tells him to try to be tough. What type of cultural behavior is this called?
Cultural imposition
A client with chronic glaucoma is being started on medication therapy with acetazolamide. The nurse teaches the client that which can occur early with the use of this medication?
Diuresis
The nurse is providing medication instructions to a parent. Which statement by the parent indicates a need for further instruction? *I should cuddle my child after giving the medication *I can give my child a frozen juice bar after he swallows the medication *I should mix the medication in the baby food and give it when I feed my child *If my child does not like the taste of the medicine, I should encourage him to pinch his nose and drink the medication through a straw
I should mix the medication in the baby food and give it when I feed my child
The nurse is reviewing the instillation technique for both eye ointment and eye drops with the parent of a pediatric client diagnosed with bacterial conjunctivitis. Which statement made by the parents would indicate that learning has taken place?
I will be careful not to touch the eye or eyelid during administration
The nurse in a health care clinic is preparing to conduct a nutritional session with a group of culturally diverse pregnant women. At the first session the nurse will be meeting with each client individually. The nurse prepares a list of items to be included in the session and lists which item as the priority?
Identify the food preferences and methods of food preparation for each client
The nurse is preparing to administer medications to a client via a percutaneous endoscopic gastrostomy tube. Which medication prescription should the nurse question? *Furosemide 20 mg via PEG tube daily *Digoxin 0.25 mg via PEG tube daily *Isosorbide mononitrate 30 mg via PEG tube daily *Acetaminophen elixir 650 mg via PEG every 4 hours as needed for temperature >101 F
Isosorbide mononitrate 30 mg via PEG tube daily
The nurse educator is orienting a new nurse to the pediatric unit and is including tips for medication administration. Which statement by the new nurse indicates that the teaching has been effective? *It helps to use magical thinking with the infant-age group *It helps to use magical thinking with the school-age group *It helps to use magical thinking with the toddler-age group *It helps to use magical thinking with the preschool-age group
It helps to use magical thinking with the preschool-age group
A client being discharged to home with a prescription for eye drops to be given in the left eye has received instructions regarding self-administration of the drops. The nurse determines that the client needs further instruction if, on return demonstration, the client takes which action?
Lies supine, pulls up on the upper lid, and puts the drop in the upper lid
The nurse is reinforcing instructions to a client about the use of an incentive spirometer. The nurse tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that which is the primary benefit?
Maintain inflation of the alveoli
A client is the child of an African American father and Asian American mother. The client has been exposed to cultural foods, traditions, and customs from both parents throughout life. What term should the nurse use to describe this client's cultural development?
Multicultural
Ear drops are prescribed for an infant with otitis media. Which is the most appropriate method to administer ear drops to an infant?
Pull down and back on the pinna, and direct the solution toward the wall of the canal
The nurse manager is giving a staff in-service on providing culturally sensitive education to clients. Which statements indicate to the nurse manager that the staff understands providing culturally sensitive education? Select all that apply.
The population served will determine the culturally sensitive resources to use for teaching, assessment of a client's preferred learning approach is essential to facilitate the learning process, it is important to have an accurate translator when the nurse and client do not speak the same language
The nurse is instructing a client on self-administration of a subcutaneous injection. The nurse is using which theoretical construct of learning?
banduras imitation
Pilocarpine hydrochloride is prescribed for a client with glaucoma. The nurse checks the medication supply room to ensure that atropine sulfate is available for administration in the event that systemic toxicity occurs from the use of pilocarpine hydrochloride. The nurse also monitors for which sign of systemic toxicity?
bradycardia
