NUR 302- Exam 1
The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response?
"Is your child breathing at this time?"
A client admitted for fever, crackles in the lungs, and cough asks the nurse, "If they do not know what type of bacteria caused my pneumonia, why are they giving me these antibiotics?" What is the appropriate response by the nurse?
"We are giving you broad spectrum antibiotics because they are active for many types of bacteria."
The nurse is making the initial assessment of a client following a surgical procedure with sedation. Place in order the nurse's assessment actions. Use all options.
-airway, breathing, and circulation -level of consciousness and orientation -intravenous access and IV fluids -wounds and tubes -items within the client's reach
A nurse is providing teaching to clients in a short-term rehabilitation facility. Which examples are common teaching mistakes made by health care professionals? Select all that apply.
-the nurse fails to accept the clients have the right to change their minds -the nurse uses medical jargon frequently when discussing the teaching plan -the nurse ignores the restrictions of the clients environment
A kindergarten student is sent to the school nurse because they have been vigorously scratching their scalp for a few hours. What is the nurse's priority action?
Assess for possible pediculosis.
An experienced nurse is teaching a student nurse about the proper use of hand hygiene. Which guideline should the nurse provide to the student?
Hand hygiene is needed after contact with objects near the client.
When a nurse is planning for learning, who must decide who should be included in the learning sessions?
The nurse and the client
A client suffers from bloody diarrhea after eating contaminated food at a local restaurant. The client has been infected with a(an):
bacteria
When an adolescent client asks the nurse how to care for long hair, the nurse should instruct the client that:
hair should be washed as often as necessary.
The nurse is preparing discharge instructions for a family member who will be caring for a client with an abdominal incision. Which concept should be the priority in the teaching plan?
hand washing
Which nursing action is a component of medical asepsis?
hand-washing after removing gloves
When educating families on fire safety, it is important to:
have a meeting place outside the home.
Which statement made by a client who was recently admitted to the medical unit with a diagnosis of pneumonia indicates a physical inability to learn?
i am having difficulty breathing
A nurse is counseling several clients for depression. Four of them do not seem to be improving, which leads the nurse to suggest a referral to a psychiatric nurse practitioner. Which of these clients would be most likely to attend the scheduled appointment?
A 28-year-old female who works nights, is willing to try, and asks about insurance coverage of the appointment
The nurse overhears an older adult client's son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers. What should the nurse do about this observation?
Ask to examine the client alone in order to speak to her privately.
Which activity is the clearest example of the evaluation step in the nursing process?
Checking the client's blood pressure 30 minutes after administering captopril
The nurse is donning a pair of sterile gloves. The nurse correctly dons the first glove, but inadvertently inserts the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which action is most appropriate?
Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole.
Which action exemplifies the purpose of evaluation in the nursing process?
Decide whether to continue, modify, or terminate client care.
As the nurse enters the room to teach the client about self-care at home, the client states, "I am glad you are here. I need some pain medicine. I can't stand it anymore." What is the best action of the nurse?
Have the client rate pain level, and reschedule the teaching session.
The client reports to the clinic as ordered by the primary care provider for counseling on weight loss to improve overall health. The client received printed information in the mail to review before the session, and reports having read through it before the appointment. Which client statement alerts the nurse to a need for clarification and further education?
I will be doing well if i can lose between 5 and 10 lb per week
A nurse is preparing to teach a 6-year-old client with a broken arm and the client's mother about caring for the child's cast. Which statement reflects the best education plan for these clients?
Include the child in the education; ask questions of both the mother and the child.
The nurse is caring for a client on the unit. During change of shift, another nurse is observed doing what is pictured in the image. What is the most important reason this technique does not adhere to the standards of care for dressing changes?
Increases the risk of infection by contaminating the wound
The nurse is performing a safety belt fit test for a young client at a well-child check-up. What criteria confirms that the child may sit in the back seat of a vehicle with a lap and shoulder belt in place?
The seat belt stays low on the hips and is not resting on the soft part of the stomach.
The nurse is performing an assessment on a client who reports having a rash on the back that is red and raised. What would be the next nursing action?
assess the clients back visually
The laboratory calls the nurse to report the client has a shift of the differential count to the left. The nurse knows this indicates the client most likely suffers from:
bacterial infection
A nurse suspects that a client has a respiratory infection. Which symptom would the nurse be least likely to assess?
clear mucus
Which developmental consideration is a nurse assessing when determining that an 8-year-old child is not equipped to understand the scientific explanation of the child's disease?
intellectual development
Select the best description of how the nurse applies the nursing process in caring for clients. The nurse:
uses critical thinking to direct care for the individual client.
The nurse observes a member of the unlicensed assistive personnel who is removing personal protective equipment (PPE) in the client's room, as seen in the image above. What education should the nurse provide to this member of the care team?
"Avoid touching the outside of your gown when removing it."
The nurse is visiting a client who was released from inpatient rehabilitation 6 weeks ago after a 5-month recovery from a motor vehicle accident that left the client immobile. As the nurse enters the home, the client braces hands on the arms of a chair to rise and uses crutches to walk across the room. What is the best response by the nurse?
"You have made an amazing recovery."
Which item would alert the home care nurse to a safety hazard threatening a young child?
Dangling blind cords
The nurse is setting up a sterile field to perform a catheterization when the client touches the end of the sterile field. What would be the nurse's next appropriate action?
Discard the sterile field and the supplies and start over.
A school nurse is providing information to a group of older adults during Fire Prevention Week. Which statement is correct regarding fires in the home?
Most people who die in house fires die of smoke inhalation rather than burns.
Which are characteristics of one who has developed critical thinking skills?
Self-aware, honest, persistent, and authentic
The nurse employs interpersonal skills of communication when caring for and interacting with clients. Which is the best example of establishing a therapeutic nurse-client relationship?
Show respect for the client, and engage in open communication in getting to know the client.
A female nurse is assisting an older man who has dementia with a bath in his hospital room. Which approach should the nurse take?
The client should be allowed to complete as much of the bath as he can.
The nurse is providing instructions to a client about performance of breast self-examination. What learning outcome would be most appropriate regarding this education?
The client will be able to perform proper breast self-examination for breast cancer detection and prevention.
The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail, the health care provider orders chemical restraints. Which treatment does the nurse anticipate?
administration of an antipsychotic agent to alter the client's behavior
A client reads the nutritional chart and follows it accurately. The nurse also notes that the client understands the need for a balanced diet and its relationship with a quick recovery. In which domain is the client demonstrating successful learning?
cognitive
When caring for a client, the nurse observes that the client enjoys reading books and magazines. In which learning domain does the client's learning style fall?
cognitive
Which step of the nursing process involves setting long-term goals and short-term expectations?
planning
Which documentation example best reflects the complexity of client teaching by the nurse?
"Client and spouse taught how to use phone app to count carbohydrates; client return demonstrated carb counting for a hypothetical meal."
A nurse is examining alternatives and judging the worth of evidence as part of preparing the plan of care for a client. The nurse would most likely be involved in which phase of the nursing process?
planning
The nurse has measured from the tip of the client's nose to the earlobe and then down to the xiphoid process before inserting a nasogastric (NG) tube and attaching it to low suction. Which components of the nursing process has the nurse demonstrated?
planning and implementing
Which term refers to a purposeful activity that leads to action, improvement of practice, and better client outcomes?
reflection
The nurse has provided teaching for a client with a sinus infection who has been prescribed antibiotics and a decongestant. The client states, "I'm not sure how many days I'm supposed to take this antibiotic." What is the nurse's appropriate response?
reteach the length of time to take the prescription
A nurse is caring for a client with limited physical mobility. The nurse has completed bathing the client and a student nurse asks, "Why are you making a trochanter roll?" After reviewing the image, which response by the nurse to the student would be most accurate?
"I am placing the new linens under the rolled, soiled linens to avoid contamination."
Which response from the client enables the nurse to determine the effectiveness of a recent medication teaching session for an older adult client who is diagnosed with tuberculosis (TB)?
"I will be taking the TB medication for at least 6 months, because it takes a long time to kill the TB germs."
The friend of a long-term care client comes to visit despite having an upper respiratory infection. What health teaching will the nurse share with the visitor?
"Please get a mask from the staff upon entry and use a mask along with hand hygiene when visiting to prevent the spread of infection to your friend and others."
The nurse has provided education to a client about home care for an open surgical wound on the lower left extremity. When evaluating learning through the cognitive domain, what statement by the nurse would be appropriate?
"Tell me about what signs of infection you will report to the health care provider."
A 56-year-old client meets with the nurse for education about a recently diagnosed atrial fibrillation. The client verbalizes concerns about being away from work too long and doubts about the necessity of having blood tests every week, as the client has no symptoms. Which is the best motivational statement by the nurse for this client?
"The medicine and blood work can help prevent blood clots, which can lead to strokes. What do you know about warfarin therapy?"
The nurse is caring for a client who is to have a sterile dressing change to a wound. A student nurse enters the client's room and notices the nurse preparing the sterile field. After reviewing the image, which response by the student nurse to the nurse is the most accurate understanding of this procedure?
"The way you are doing it helps to minimize contamination of the non-waterproof side."
Several family members are visiting a client with an antibiotic-resistant infection who has been placed on contact precautions. When the nurse teaches the visitors about wearing gloves and gowns, a family member states, "I don't want to wear those. I can't catch anything just by holding my loved one's hand." What is the best response to educate the family about infection transmission?
"These barriers help prevent the transmission of infection to you or other people."
The client presents to the Emergency Department reporting fever, chills, and a productive cough. The chest x-ray shows an area of infiltrate, and the primary care provider prescribes a broad spectrum antibiotic. Which client teaching statement from the nurse is most appropriate regarding the prescribed drug?
"This antibiotic is the best choice since the causative organism is not known."
The nurse cares for a client who is postoperative after an abdominal surgery. Which is the most important statement for the nurse to use in teaching this client?
"Use the call bell for any needs and wear nonslip footwear."
The nurse has provided a family with education related to car seat safety for a 9-month-old infant. Which statement indicates an understanding of the teaching?
"We place our infant in a rear-facing car seat in the back seat of the car."
An older adult woman in a long-term care facility has fallen and sustained a hip fracture. The nurse would ask which question(s) to assess possible causes of the fall? Select all that apply.
-"Did you experience dizziness prior to the fall?" -"Can you tell what you were doing before you fell?" -"Did you have pain in your hip prior to the fall?" -"Is it possible you may have tripped over a rug or a cord?"
A nurse is evaluating the effectiveness of health promotion teaching related to hygiene at a community workshop. Which statements by one of the participants requires further teaching to ensure understanding? Select all that apply.
-"It is important to brush your teeth regularly but flossing is not necessary since it can damage the gums." -"Hygiene does not contribute to my well-being so I can choose to not perform hygiene." -"Hygiene measures have no affect on skin."
When developing a nursing plan of care and associated client outcomes, what should the nurse recognize? Select all that apply.
-A plan of care should be comprehensive and ongoing, covering and being updated during all phases of care. =Outcomes can be short- and long-term. -Outcome setting allows for individualization of the plan of care.
The nurse is in the evaluation phase of the nursing process when developing the plan of care for a client. What should the nurse determine this phase will include? Select all that apply
-Evaluation is the last part of the nursing process -evaluation should be documented daily in the clients record -The evaluation is used to determine decisions about terminating, continuing, or modifying the plan of care.
Which statements are true about informatics in nursing practice? Select all that apply.
-Nurses should value technologies that support error prevention and care coordination. -The use of informatics can help manage knowledge and mitigate error. -Utilization of information services helps to support decision making.
The nurse performs personal hygiene, including bathing, for an immobile client. What benefit(s) is the client gaining? Select all that apply.
-Promotes relaxation and comfort -Increases circulation -Helps maintain muscle tone and joint mobility -Reduces the risk of acquiring multidrug-resistant organisms
A nurse has completed a client assessment and is preparing to identify appropriate nursing concerns. Which area(s) will the nurse likely address in the nursing concern? Select all that apply.
-altered mobility -altered nutrition -ineffective coping
The nurse is preparing to perform handwashing. Place the following steps in the correct order. Use all options.
1. Turn on the faucet and adjust force and temperature of the water. 2. Wet the hand and wrists. 3. Apply soap. 4. Wash the palms and backs of the hands for at least 20 seconds. 5. Pat the hands dry with a paper towel. 6. Turn the faucet off with a paper towel.
A client is being screened for a parasitic infection and the health care provider orders stool specimens. When explaining to the client about collecting the specimens, the nurse would inform the client that the specimens will be collected daily for:
3 days
A nurse caring for clients in a skilled nursing facility assesses client motivation to participate in care. Based on the health belief model, which clients would be most motivated? Select all that apply.
A client who views a disease as a serious threat, A client who believes there are actions that will reduce the probability of contracting the disease, A client who believes that the risks of taking action against a disease are not as great as the risks posed by the disease itself
The nurse is caring for a client who presents with polydipsia, polyphagia, and polyuria. The client's laboratory test results reveal an increased HgbA1C level, which could indicate increased blood glucose levels. What is the next step for the nurse to take based on the nursing process?
Analyze the data and create an individualized nursing concern for care planning.
The client has Alzheimer disease and is a new admission to the nursing home. The client was transferred from the hospital. When first meeting the client, what technique(s) will the nurse use to facilitate communication with this client? Select all that apply.
Approach the client from the front of the client, call the client by the clients preferred name, use simple words and short sentences when talking with the client
A nurse is working with a 15-year-old client with sickle cell anemia. The client was started on a new pain management plan today, and the nurse is evaluating the effectiveness of the plan. Which is not appropriate to include in the nursing care?
Asking only the client's parents to be present at the education session
The nurse must instruct a 35-year-old client with Down syndrome about the use of an albuterol rescue inhaler. Which documentation demonstrates appropriate individualization of the education plan for this client?
Assessed the client's understanding of illness; assessed motor skills and developmental stage; provided clarification
A client informs the nurse about being committed to quitting smoking to improve health. During discussion, the nurse asks the client "on a scale of 0 to 10, how likely are you to attend a support group?" Which strategy of motivational interviewing is the nurse using with the client?
Assessing importance
A nurse has finished providing care for a client who is on contact precautions. When removing the protective gown, the nurse should take which action?
Avoid touching the outer surfaces of the gown.
The nurse is caring for a 60-year-old client with an improper bowel movement regimen. Which is the most appropriate method for the nurse to use in teaching this client?
Begin the session with a reference to the client's actual experience.
A nurse is educating a 4-year-old client about cast care following a tibia-fibula fracture. Which action is not developmentally appropriate to include in the nurse's teaching?
Blocking 30 minutes of time for skill teaching
The nurse is preparing to teach a client from Generation X about hypertension. Which teaching approach should the nurse plan to implement?
Demonstrate the MyFoodPyramid phone app, to show the best food choices on a lunch tray.
A client diagnosed with type 2 diabetes has been prescribed insulin therapy in conjunction with an oral agent because the client has been experiencing difficulty controlling blood sugar levels with an oral agent alone. The nurse is preparing a teaching plan for this client. Which intervention would the nurse include in the teaching plan to address the psychomotor domain?
Demonstrating the technique for insulin self-injection
A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed, the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do?
Determine whether the prescribed treatment was effective.
The nurse has finished caring for a client on contact precautions. Which nursing action regarding the stethoscope used to auscultate this client's lungs and bowel sounds is appropriate?
Disinfect it with alcohol swabs.
The nurse is inserting a foley catheter for a client. Which nursing action is appropriate if the sterile field is broken during this procedure?
Don another pair of sterile gloves.
The nurse needs to understand the teaching-learning process when administering
Education intervention
Research has demonstrated that a common source of hospital-acquired infections in clients with intravenous (IV) infusions is the hub on the IV tubing. Which nursing practice competency is displayed when health care institutions recommend that health care providers always wash hands and wear gloves when accessing the hubs of IV tubing?
Evidence-based practice
A child who appears to have a cold sneezes repeatedly in the waiting room without covering the mouth. Which action should the nurse take?
Give the child a box of tissues and ask to cover the face with a tissue every time he sneezes.
A nurse is implementing the principles of surgical asepsis while inserting a client's indwelling urinary catheter. Which action should the nurse perform?
Hold sterile objects above waist level to prevent accidental contamination.
Which developmental consideration is a nurse assessing when determining that an 8-year-old child is not equipped to understand the scientific explanation of the child's disease?
Intellectual development
Which statement best conveys the role of intuition in nurses' problem solving?
Intuition can be a clinically useful adjunct to logical problem solving.
A new mother has brought her infant into the pediatric clinic. The infant has a red rash on the buttocks. What should the nurse instruct the mother?
Keep the diaper and buttocks clean and dry and apply zinc oxide.
The nurse enters the room of an adult client who reports postoperative abdominal pain. The client states that the pain is severe but is relieved some when getting up to go the bathroom. Which is the nurse's best determination based on this assessment?
More assessment would be beneficial to determine whether pain medication is desirable.
Which nursing action is applicable to the psychomotor domain of learning when conducting a teaching session for breastfeeding mothers?
Observing a mother expressing the breast milk
An active, otherwise healthy, older adult client presents to the clinic with severe osteoarthritis in both knees. The nurse knows this client does not want to be a burden on the family, and the client remains stoic despite reporting the pain as severe. The client avoids the topic of surgery and attends church weekly. The client's family is supportive of any decisions the client makes regarding health. Which of the assessment data is most important to forming an individualized education plan for this client concerning treatment for osteoarthritis?
Personal perception of health and aging
A nurse is providing care for a client who has had gall bladder surgery. It is the first postoperative day and the client is exhibiting a fever. The nurse suspects what as the most likely cause?
Physiologic stress
The nurse is teaching the caregiver of a 3-year-old about safety. Which teaching will the nurse include?
Place all household cleaners out of reach.
A nurse has developed a plan of care for an adult client. What nursing function is important when using the identified nursing concerns to guide the care of this client?
Prioritize the nursing concerns.
Which is the best example of person-centered care provided by a registered nurse?
Reassuring a client who is anxious about a procedure
The nurse is caring for an obese client who needs to be turned every 2 hours. Which action by this nurse is an example of reflection-for-action?
Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care.
Which strategy should the nurse use when providing education to the older adult client?
Remain calm and conduct the teaching session in a quiet environment.
Which nursing action is appropriate when providing foot care for a client?
Rinse the feet, dry thoroughly, and apply moisturizer on the tops and bottoms.
Which statement is true of the nursing process?
Scientific problem solving can occur within the nursing process.
The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this client?
Take the restraints off, stay with her, and talk gently to her.
When teaching a client, the nurse notices the client tends to lose focus easily. The nurse would adapt client teaching in which way?
Talk with animation and vocal inflection to stimulate the client aurally
When teaching a client, the nurse notices the client tends to lose focus easily. The nurse would adapt client teaching in which way?
Talk with animation and vocal inflection to stimulate the client aurally.
The nurse has provided education to a client about home care for an open surgical wound on the lower left extremity. When evaluating learning through the cognitive domain, what statement by the nurse would be appropriate?
Tell me about what signs of infection you will report to the health care provider
The nurse is educating a client regarding a new skill. When evaluating the client's knowledge about the topic covered, which best represents that the client has learned a new skill?
The client organizes materials needed and gives return demonstration
A nurse has identified the client's lack of knowledge regarding their prescribed antibiotic therapy. Which outcome is appropriate for the nurse to include in the client's care plan based on this nursing concern?
The client will state how to safely take the prescribed antibiotic.
While applying dressings to a client's wound, the nurse teaches the client about wound care. To promote the most effective teaching-learning relationship with this client, what would be most important for the nurse to keep in mind?
The nurse and client relationship is based on mutual sharing and negotiation
While applying dressings to a client's wound, the nurse teaches the client about wound care. To promote the most effective teaching-learning relationship with this client, what would be most important for the nurse to keep in mind?
The nurse and client relationship is based on mutual sharing and negotiation.
The nurses on a busy surgical ward use hand hygiene when caring for postsurgical clients. Which action represents an appropriate use of hand hygiene?
The nurse keeps fingernails less than 1/4 in (0.63 cm) long.
When teaching an adult client how to control stress through relaxation techniques, the nurse should proceed on the basis of which assumption concerning adult learners?
The nurse should be able to draw from the previous experience of the client to emphasize the importance of stress reduction.
A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities?
The nurse should question the client about the source of the bruises.
A parish nurse is preparing to provide a health promotion class to a group of adults in the parish. In preparing to meet the learning needs of this group, the nurse recognizes which as a characteristic of an adult learner?
Their readiness to learn is often related to a developmental task or social role
The nurse is preparing to apply a prescription ointment to the client's wound. After reviewing the image, what is the most important step for the nurse to take?
Use a sterile cotton-tipped applicator to apply the prescription to the site
The nurse is preparing to insert an intravenous catheter into a client. Which infection control procedure will the nurse use to ensure safe client care?
Use a sterile intravenous catheter.
The nurse is developing a plan of care for a client with a fractured femur who is in traction and will be restricted to bed for some time. Which domain should the nurse consider when developing a nursing diagnosis based on this client's musculoskeletal health problems?
activity and rest
Which guideline is most important for the nurse to keep in mind when planning to teach an exercise class to a group of older adults?
allow ample time for psychomotor skills
The nurse is making morning rounds after receiving reports on clients. The nurse takes the opportunity to greet the clients and do an initial observation. The nurse is actually accomplishing which step of the nursing process?
assessment
An occupational health nurse is planning in-service training sessions for the employees. Which teaching topic would be most appropriate to cover with these clients?
cardiopulmonary resuscitation
The nurse is caring for a client with tuberculosis. The prior shift's nurse has placed the client in droplet precautions. Which is the appropriate nursing action?
change to airborne precautions
A client has a diagnosis of Bathing/Hygiene Self-care Deficit due to recent surgery and decreased strength. An appropriate goal to include in the client's plan of care would be:
client will participate in self-care measures by the end of the week.
The nurse has educated the client on the pathophysiology of osteoarthritis and degenerative joint disease. This type of teaching best illustrates which learning theory?
cognitive learning theory
A client has had major abdominal surgery and just returned to the unit from the operating room. The nursing priority is to:
complete the postoperative assessment.
A client's body mass index (BMI) categorizes the client as obese. Thc client comes to the clinic to start on a weight loss plan. The client loves to eat, does not like to exercise, and their favorite food is hamburgers. The nurse creates a care plan focused on the nursing concern altered health maintenance. What is the most appropriate outcome for this concern? The client will:
create an exercise plan that is realistic and valued.
A client shares with the nurse how much the client appreciates understanding the physiology of breastfeeding. The client states, "I felt very comfortable with what you explained to me, and I feel I will be successful at breastfeeding." In affective learning, this represents the nurse:
creating an atmosphere for discussion of feelings.
A nurse is working with an older adult client, educating the client on how to ambulate with the aid of a walker. The nurse notes that the client appears to lack the motivation to learn how to use the device. The client states, "I'm just too old to learn." What would be most appropriate for the nurse to do to motivate this client?
describe how the walker can improve the clients quality of life
The nurse is attentive and responsive to the health care needs of individual clients and ensures the continuity of care when leaving these clients. What interpersonal skill is the nurse displaying?
developing accountability
A near miss has taken place on a medical unit in which a client nearly received a unit of packed red blood cells of an incompatible blood type. In the follow up to this event, which action should be prioritized?
identifying systemic factors on the unit that may have contributed to the event
The nurse has completed a comprehensive assessment of a client who has been admitted to the hospital experiencing acute withdrawal from alcohol. What identified nursing concern provides the clearest justification for the use of physical restraints during this client's care?
injury risk related to agitation
A client is admitted to the hospital with an abscess on the leg that will not heal after multiple treatment options as an outpatient. The nurse knows from past experiences that the appearance of this type of wound in clients heavily suggests a resistant bacterial infection and the need for contact isolation and intravenous antibiotics. The nurse begins to prepare for this admission. What type of problem solving does this exhibit?
intuitive
The nurse is assisting with the creation of a plan of care for a client with newly diagnosed diabetes mellitus. When creating the plan of care, what is the priority action for the nurse?
involving the client with all the steps of the process in care development
A client is admitted to the emergency department for multiple lacerations due to a vehicular accident. After wound care, the doctor writes an order for Tdap (Tetanus-diphtheria-pertussis) vaccination. The primary reason for this vaccine is:
it is a vaccine given to booster antibodies towards the tetanus pathogen.
What is the most appropriate teaching strategy for the nurse to use for a 1-hour presentation on the prevention of osteoporosis to a group of 30 college-age women?
lecture and discussion
A modern approach to the development of clinical decisions and clinical judgments is the use of human client simulators in simulation laboratories on campus. Human client simulators are best described as:
life-sized mannequins with a sophisticated computer interface.
The nurse is caring for a client with an identified nursing concern of fluid volume deficiency. The nurse has implemented the plan of care and on evaluation finds that the client continues to exhibit symptoms of fluid volume deficiency. What should the nurse do next?
modify the plan of care and interventions to meet the clients needs
When a client says, "I don't care if I get better; I have nothing to live for, anyway," which type of counseling would be appropriate?
motivational counseling
A nurse identifies the following: "The client will report a pain rating of 4 or less within 30 to 45 minutes of receiving prescribed analgesic." The nurse has identified:
outcome.
An active, otherwise healthy, older adult client presents to the clinic with severe osteoarthritis in both knees. The nurse knows this client does not want to be a burden on the family, and the client remains stoic despite reporting the pain as severe. The client avoids the topic of surgery and attends church weekly. The client's family is supportive of any decisions the client makes regarding health. Which of the assessment data is most important to forming an individualized education plan for this client concerning treatment for osteoarthritis?
personal perception of health and aging
A 46-year-old obese client has been diagnosed with hypertension and type 2 diabetes. The client acknowledges the need to lose weight. The client recently visited a local fitness club, obtained a membership, and has signed up for their next water aerobics class. According to the Transtheoretical Model of Change, what stage of change is this client in related to her weight loss?
preparation
A nurse assisting a new mother in the act of breastfeeding represents which form of learning?
psychomotor
When caring for a diabetic client, the nurse notes that the client learns better when practicing the self-administration of the insulin injection alone. In which learning domain does this client's learning style fall?
psychomotor
The nurse has worn a gown and gloves while caring for a client in contact isolation. How will the nurse appropriately remove this personal protective equipment (PPE)?
remove gloves, remove gown, wash hands
The nurse observes an unlicensed assistive personnel (UAP) collecting a urine specimen from a client with Staphylococcus aureus infection. Which action by the UAP would require the nurse to intervene?
removes gloves and walks out of the room
The nurse administers pain medication to a postoperative client. Which nursing intervention will assist with the client's unrelieved pain?
reposition the client
The most common infection in children is:
respiratory
The nurse is conducting a community health promotion class and has developed scenarios that will involve active participation by the class attendees. What type of education strategy is the nurse incorporating into this class?
role playing
A nurse may attempt to help a client solve a situational crisis during what type of counseling session?
short term counseling
The health care provider notified the client and the spouse that the client's condition was terminal. The spouse has been crying since the interaction with the health care provider. The nurse is going to talk with the spouse about the spouse's feelings. What action(s) would the nurse do to promote a positive impression with the spouse? Select all that apply.
sit at eye level with the spouse, maintain eye contact more than half the time, lean forward slightly, hold the spouses hand during the interaction
What type of intervention is the nurse performing when the nurse observes the spouse of a postoperative client performing the client's dressing change?
supervisory
The nurse is working at a local elementary school. A mother arrives to pick up her 6-year-old son and has her 2-year-old daughter in tow. Based on the nurse's developmental knowledge of toddlers, which behavior would most concern the nurse?
the 2-year-old leaning against the screen of a window in a classroom
A client has a diagnosis of HIV and has been admitted to the hospital with an opportunistic infection that originated with the client's normal flora. Why did this client most likely become ill from his resident microorganisms?
the clients immune system becomes further weakened
When a nurse is planning for learning, who must decide who should be included in the learning sessions?
the nurse and the client
The nurse is caring for a female client who is unconscious. The nurse should pay special attention to cleaning which area of the body?
underneath the breasts and in between skinfolds
A nurse is caring for a 55-year-old postoperative client. The client returns to the ICU after surgery intubated and mechanically ventilated with a Salem sump nasogastric tube, a Foley catheter, and a PICC line in place. Based on the nurse's knowledge of the most common hospital-acquired infections, which apparatus is most important to remove first?
urinary catheter
While the nurse is caring for a hearing impaired client, and a family member of the client states, "What do you think is the best way to communicate?" What is the best response by the nurse?
use flash cards and writing pad
Which care intervention should the nurse anticipate when providing care to a client admitted with a possible diagnosis of tuberculosis (TB)?
wearing a particulate respirator for all care and interaction with this client
