NUR 233 Exam #4
A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? A. Move the client next to the nurses' station B. Use an indirect light source and turn off the TV C. Keep the TV and a soft light on during the light D. Play soft music during the night, maintain a well-lit room
B
The male client tells the nurse he has been experiencing "heartburn" at night that awakens him. Which assessment question should the nurse ask? A. "How much weight have you gained recently" B. "What have you done to alleviate the heartburn" C. "Do you consume many milk and dairy products" D. "Have you been around anyone with a stomach virus"
B
The nurse is caring for an elderly client who has an indwelling catheter. Which data warrants further investigation? A. Clients temp 98 B. client becomes confused and irritable C. clients urine clear/light yellow D. client feels need to urinate
B
The nurse is caring for an older client following surgical repair of a hip fracture. On assessment of the client, the nurse notes that the client is disoriented and is attempting to get out of bed. Which is the most appropriate initial nursing intervention. A. Apply restraints to the client B. Place a bed alarm pad under the patient C. Collaborate with the HCP for a prescription for a sedative D. Have the UAP check the client every half-hour
B
Which finding should nurse expect when assessing a client with osteoarthritis of the knee? A. Presence of Heberden's nodules B. Discomfort with joint movement C. Redness and swelling of knee joint D. Stiffness that increases with movement
B
Which nursing intervention should be included in the care plan for the 84 y/o diagnosed with gastroenteritis? Select All A. Assess skin turgor on back of hand B. monitor for ortho hypo C. record frequency and characteristics of sputum D. Use standard precautions when caring for client E. institute safety precautions when ambulating client
B D E
A patient with Alzheimer's disease who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care? A. Reorient the patient several times daily B. Have the family bring in familiar items C. Place the patient in a room close to the nurse's station D. Remind the patient not to wander from the nursing unit
C
The client being admitted from the ED is diagnosed with a fecal impaction. Which nursing intervention should be implemented: A. administer an antidiarrheal med every day prn b. perform bowel training every 2 hours c) Administer an oil retention enema d) Prepare for an UGI X-ray
C
The client presents to the outpatient clinic complaining if diarrhea for 2 days. Which laboratory data should the nurse monitor? A. Sodium level B. Albumin level C. Potassium level D. Glucose level
C
The nurse is caring for a client with Parkinson's disease. Which finding about gait should the nurse expect to note in the client? A. walking on toes B. unsteady and staggering C. shuffling and propulsive D. broad-based and waddling
C
The nurse is examining an 18-year old who is complaining of pain, frequency and urgency. Which question should the nurse ask first. A. Have you noticed any change in color? B. When was your last menstrual cycle? C. Are you sexually active? D. What have you taken for the pain?
C
The nurse is preparing for a client diagnosed with GERD for surgery. Which information warrants notifying the HCP? A. The client's Bernstein esophageal test was positive B. The client's abdominal x-ray shows a hiatal hernia C. The client's WBC is 14,000 D. The client's hemoglobin is 13.8
C
A patient who had open reduction and internal fixation of the left lower leg fractures continues to report severe pain in the leg 15 mins after receiving the prescribed IV morphine. The nurse determines pulses are faintly palpable and the foot is cool to the touch. Which action should the nurse take next? A. Notify the HCP B. Assess the incision for redness C. Reposition the left leg on the pillow D. Check the patient's blood pressure
A
For a patient who has had a right hip arthroplasty, which nursing action can the nurse delegate to experienced UAP? A. Reposition the patient every 1-2 hours B. Assess for skin irritation on the patient's back C. Teach the patient quadriceps-setting exercises D. Determine the patient's pain intensity and tolerance
A
The client is diagnosed with a hiatal hernia is scheduled for a laparoscopic Nissen fundoplication. Which statement indicates the nurse's teaching is effective? A. "I will have 4-5 small incisions" B. "I will be in the hospital for at least 1 week" C. "I will not have any pain because this is a laparoscopic surgery" D. "I will be returning to work the day after my surgery"
A
The nurse is developing a plan of care for a client with late-stage Alzheimer's disease. The nurse identifies which client problem as having the highest priority? A. Risk for injury B. social isolation behaviors C. role performance D. inability to communicate verbally
A
The nurse notes that an older client with dementia is unable to care for herself. Which is an appropriate goal for this client? A. Client will function at highest level of independence possible throughout the stay B. the client will be admitted to long-term care facility to have ADLs met C. The nursing staff will attend to all clients ADL needs during hospital stay D. The client will complete all ADL independently within 1 hour time frame
A
Which information indicates to the nurse the client teaching about treatment of urinary incontinence has been effective? A. client prepares a scheduled voiding plan B. client verbalizes the need to increase fluid intake C. client explains how to perform pelvic floor exercises D. client attempts to retain vaginal cone in entire day
A
Which nursing problem is priority for the 76-year-old client diagnosed with gastroenteritis from staphylococcal food poisoning? 1. Fluid volume deficit. 2. Nausea. 3. Risk for aspiration. 4. Impaired urinary elimination.
A
Which problem is most appropriate for the nurse to identify for the client with diarrhea A. Alteration for skin integrity B. Chronic pain perception C. fluid volume excess D. ineffective coping
A
the nurse and UAP are caring for clients on a med-surg unit. which task should not be assigned to the UAP? a. feed a 69 y/o client with Parkinson's disease who is having difficulty swallowing b. turn and position the 89 y/o client with pressure ulcer secondary to Parkinson's disease c. assist the 54 y/o client diagnosed with Parkinson's with toileting d. obtain vital signs on a 72 yo diagnosed with pneumonia secondary to Parkinson's disease
A
Which of the following physical changes seen at the end-of-life? Select all A. decreased urination B. mottling of hands and feet C. loss of gag reflex D. increased BP E. difficulty speaking
A B C E
The client diagnosed with AIDS is experiencing diarrhea. Which intervention should the nurse implement? Select all A. Monitor diarrhea amount character/consistency B. assess clients skin turgor every day C. encourage client to drink carbonation D. weight client daily in same clothes and time E. assist the client with warm sitz bath PRN
A D E
A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention by the nurse? A. Using crutches with a swing to gait B. Sitting upright on the edge of the bed C. Leaning over to pull on shoes and socks E. Bending over the sink while brushing teeth
C
An older client is brought to the ED by a neihbor who heard the client talking and found him wandering in the street at 3 am. The nurse should first determine which data about the client. A. his insurance status B. blood toxicology levels C. whether he ate an evening meal D. whether this is a change in usual level of orientation
D
As the nurse admits a patient in end-stage renal disease to the hospital, the patient tells the nurse "if my heart or breathing stop, I do not want to be resuscitated." Which action should the nurse take first? A. Place DNR notation in patients care plan B. Invite the patient to add a notarized advance directive in the health record C. Advise the patient to designate a person to make future health care decisions D. Ask if the decision has been discussed with the patient's health care provider
D
D.B. is admitted to a long-term facility. He has a nursing diagnosis for impaired memory related to effects of dementia. An appropriate nursing intervention for him is to A. Let him know what behavior is socially appropriate B. Assist him with all self-care to maintain self-esteem C. Maintain familiar routines of sleep, meals, meds and activities D. Promote orientation at every encounter with patient by asking day, time, place
D
The nurse is caring for a client diagnosed with GERD. Which nursing intervention should be implemented? A. Place the client prone in bed and administer NSAIDS B. Have the client remain upright at all times and walk for 30 mins 3x week C. Instruct the client to maintain a right late4ral side-lying position and take antacids before meals D. Elevate the HOB 30 degrees and discuss lifestyle modifications with the client
D
Which menu choice with osteoporosis indicates the nurse's teaching about appropriate diet has been effective? A. Pancakes with syrup and bacon B. Whole wheat toast and fresh fruit C. Egg-whites omelet and a half grapefruit D. Oatmeal with skim milk and fruit yogurt
D
